Healthcare Provider Details

I. General information

NPI: 1922854249
Provider Name (Legal Business Name): NICOLE LEIGH HURLESS PHD, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NIKKI HURLESS PHD, LPC

II. Dates (important events)

Enumeration Date: 04/26/2024
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 N RIVERSIDE DR
FORT WORTH TX
76111-2732
US

IV. Provider business mailing address

8217 DOWNE DR
FORT WORTH TX
76108-3005
US

V. Phone/Fax

Practice location:
  • Phone: 806-402-1163
  • Fax:
Mailing address:
  • Phone: 410-920-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number88529
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: