Provider Demographics
NPI:1114035227
Name:HURSTON, MICHAEL (OT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:HURSTON
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 11TH ST SE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-9168
Mailing Address - Country:US
Mailing Address - Phone:541-347-4314
Mailing Address - Fax:541-347-8006
Practice Address - Street 1:913 11TH ST SE
Practice Address - Street 2:SUITE 1
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9168
Practice Address - Country:US
Practice Address - Phone:541-347-4314
Practice Address - Fax:541-347-8006
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR979681225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028176Medicaid