Healthcare Provider Details

I. General information

NPI: 1225091929
Provider Name (Legal Business Name): MICHAEL THOMAS HURLOCK SPEECH PATHOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EMANCIPATION DR
HAMPTON VA
23667-0001
US

IV. Provider business mailing address

9 GREAT LAKES DR
HAMPTON VA
23669-2387
US

V. Phone/Fax

Practice location:
  • Phone: 757-722-9961
  • Fax:
Mailing address:
  • Phone: 757-722-9961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202001040
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: