Basic Information
| Provider Information | |||||||||
| NPI: | 1962698969 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HURD | ||||||||
| FirstName: | ALEXIS | ||||||||
| MiddleName: | RACHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HURD-SHIRES | ||||||||
| OtherFirstName: | ALEXIS | ||||||||
| OtherMiddleName: | RACHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 612 SE JACKSON ST STE 11 | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974704956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414646455 | ||||||||
| FaxNumber: | 5414646457 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 SE JACKSON ST STE 11 | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974704956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414646455 | ||||||||
| FaxNumber: | 5414646457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2007 | ||||||||
| LastUpdateDate: | 10/12/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | T-LMSW 6923 | KS | N | Behavioral Health & Social Service Providers | Social Worker | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.