Healthcare Provider Details

I. General information

NPI: 1851994123
Provider Name (Legal Business Name): KAELLIE HURST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 JD TOWLES DR
WILLOW PARK TX
76087-8654
US

IV. Provider business mailing address

161 JD TOWLES DR
WILLOW PARK TX
76087-8654
US

V. Phone/Fax

Practice location:
  • Phone: 682-900-1444
  • Fax: 432-322-4597
Mailing address:
  • Phone: 682-900-1444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: