Basic Information
| Provider Information | |||||||||
| NPI: | 1316318728 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KERSTIN P. HURLEY, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 CALLE PORTAL | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856352900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204593012 | ||||||||
| FaxNumber: | 5204593207 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 CALLE PORTAL | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856352900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204593011 | ||||||||
| FaxNumber: | 5204584467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2015 | ||||||||
| LastUpdateDate: | 12/31/2015 | ||||||||
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| AuthorizedOfficialLastName: | MELK | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5203641429 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY 27306 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 4689 | 01 | AZ | ARIZONA STATE BOARD OF PSYCHOLOGY | OTHER |