Provider Demographics
NPI:1235101007
Name:HEARST, CARYL L (PSY D)
Entity Type:Individual
Prefix:DR
First Name:CARYL
Middle Name:L
Last Name:HEARST
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 N MAIN ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501
Mailing Address - Country:US
Mailing Address - Phone:303-744-7410
Mailing Address - Fax:303-776-7693
Practice Address - Street 1:1707 N MAIN ST
Practice Address - Street 2:SUITE 404
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501
Practice Address - Country:US
Practice Address - Phone:303-744-7410
Practice Address - Fax:303-776-7693
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1251103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98506Medicare ID - Type Unspecified