Healthcare Provider Details

I. General information

NPI: 1861418626
Provider Name (Legal Business Name): MARY JANE HURT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 CAMPBELL AVE SW
ROANOKE VA
24016-3625
US

IV. Provider business mailing address

360 CAMPBELL AVE SW
ROANOKE VA
24016-3625
US

V. Phone/Fax

Practice location:
  • Phone: 540-563-5316
  • Fax: 540-563-5254
Mailing address:
  • Phone: 540-563-5316
  • Fax: 540-563-5254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904000813
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: