Healthcare Provider Details

I. General information

NPI: 1063089852
Provider Name (Legal Business Name): CARLY GRACE HURDLE BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2008 GENERAL BOOTH BLVD
VIRGINIA BEACH VA
23454-5910
US

IV. Provider business mailing address

5505 MACGUFFIE ST
VIRGINIA BEACH VA
23464-7105
US

V. Phone/Fax

Practice location:
  • Phone: 757-271-6980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-2830909
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: