Provider Demographics
NPI:1174018162
Name:HURT, PRISCILLA
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:HURT
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 1:9330 MEDICAL PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9104
Mailing Address - Country:US
Mailing Address - Phone:707-334-4543
Mailing Address - Fax:
Practice Address - Street 1:9330 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9104
Practice Address - Country:US
Practice Address - Phone:843-847-3057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC107851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical