Healthcare Provider Details

I. General information

NPI: 1790554434
Provider Name (Legal Business Name): AMY L HURLBURT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 SILICON DR
SOUTHLAKE TX
76092-9018
US

IV. Provider business mailing address

990 TROPHY CLUB DR
TROPHY CLUB TX
76262-5482
US

V. Phone/Fax

Practice location:
  • Phone: 817-755-0491
  • Fax:
Mailing address:
  • Phone: 817-876-7048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number86478
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: