Healthcare Provider Details

I. General information

NPI: 1124672969
Provider Name (Legal Business Name): SHANNON HURLBUT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 S. WALNUT ST.
APPLETON WI
54911-5918
US

IV. Provider business mailing address

320 S. WALNUT ST.
APPLETON WI
54911-5918
US

V. Phone/Fax

Practice location:
  • Phone: 920-832-5270
  • Fax: 920-832-4767
Mailing address:
  • Phone: 920-832-5270
  • Fax: 920-832-4767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number127443
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11131-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: