Provider Demographics
NPI:1073107975
Name:HURD, MONIQUE L
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:L
Last Name:HURD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3941 ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44121-2411
Mailing Address - Country:US
Mailing Address - Phone:216-256-4875
Mailing Address - Fax:
Practice Address - Street 1:3941 ORCHARD RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44121-2411
Practice Address - Country:US
Practice Address - Phone:216-256-4875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0120949Medicaid