Basic Information
| Provider Information | |||||||||
| NPI: | 1609311661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HURLEY | ||||||||
| FirstName: | KIA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 E BAGLEY RD | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440172058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402608300 | ||||||||
| FaxNumber: | 4402348319 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 CARNEGIE AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441152641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402608900 | ||||||||
| FaxNumber: | 4402608576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2016 | ||||||||
| LastUpdateDate: | 12/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C.1000107 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.