Healthcare Provider Details

I. General information

NPI: 1396397337
Provider Name (Legal Business Name): STEPHANIE HURLBURT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4076 KOTHLOW AVE
MENOMONIE WI
54751-3090
US

IV. Provider business mailing address

6126 GARRETT LN
ROCKFORD IL
61107-5230
US

V. Phone/Fax

Practice location:
  • Phone: 715-235-4537
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: