Basic Information
| Provider Information | |||||||||
| NPI: | 1992959951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HURST | ||||||||
| FirstName: | CANDY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 12276 SAN JOSE BLVD | ||||||||
| Address2: | SUITE 508 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322238628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048863228 | ||||||||
| FaxNumber: | 9048863297 | ||||||||
| Practice Location | |||||||||
| Address1: | 12276 SAN JOSE BLVD | ||||||||
| Address2: | SUITE 508 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322238628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048863228 | ||||||||
| FaxNumber: | 9048863297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2008 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 0-08-2541 | 01 | FL | BACB CERTIFICANT | OTHER |