Provider Demographics
NPI:1083370225
Name:HURLEY, SHANE CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:CHRISTOPHER
Last Name:HURLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 E 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-3602
Mailing Address - Country:US
Mailing Address - Phone:606-603-0747
Mailing Address - Fax:
Practice Address - Street 1:1804 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-3602
Practice Address - Country:US
Practice Address - Phone:216-762-1237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYH10-068-103101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)