Provider Demographics
NPI:1073069563
Name:HURT, LALESCIA LAVONE (PEER SUPPORT SPECIAL)
Entity Type:Individual
Prefix:
First Name:LALESCIA
Middle Name:LAVONE
Last Name:HURT
Suffix:
Gender:F
Credentials:PEER SUPPORT SPECIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8809 GRAND DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44125-1349
Mailing Address - Country:US
Mailing Address - Phone:216-470-2998
Mailing Address - Fax:
Practice Address - Street 1:8809 GRAND DIVISION AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44125-1349
Practice Address - Country:US
Practice Address - Phone:216-470-2998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist