MEDICARE: DR. RANDALL DEAN HURST PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PY2237	WA

General Provider Information

NPI Number	:	1942306949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDALL DEAN HURST PSY.D.

Provider Business Mailing Address
First Line	:	945 11TH AVE
Second Line	:	SUITE B
City	:	LONGVIEW
State	:	WA
Zip	:	98632-2555
Country	:	US
Telephone Number	:	360-414-8600
Fax Number	:	360-636-7372

Provider Business Practice Location Address
First Line	:	945 11TH AVE
Second Line	:	SUITE B
City	:	LONGVIEW
State	:	WA
Zip	:	98632-2555
Country	:	US
Telephone Number	:	360-414-8600
Fax Number	:	360-636-7372

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	07/08/2007

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