Healthcare Provider Details

I. General information

NPI: 1245689280
Provider Name (Legal Business Name): KIMBERLY ANN SLAVICH HURD LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 LISBON ST
FORT WORTH TX
76107-5601
US

IV. Provider business mailing address

1905 RIO COSTILLA RD
FORT WORTH TX
76131-1655
US

V. Phone/Fax

Practice location:
  • Phone: 817-320-2094
  • Fax:
Mailing address:
  • Phone: 817-320-2094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number69573
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: