Provider Demographics
NPI:1639335813
Name:HURLOCK, MICHAEL THOMAS (PHD LMFT LPC NCC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:HURLOCK
Suffix:
Gender:M
Credentials:PHD LMFT LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 DUNHAM POND ROAD
Mailing Address - Street 2:
Mailing Address - City:STORRS
Mailing Address - State:CT
Mailing Address - Zip Code:06268
Mailing Address - Country:US
Mailing Address - Phone:860-477-0497
Mailing Address - Fax:860-477-0532
Practice Address - Street 1:9 DUNHAM POND ROAD
Practice Address - Street 2:
Practice Address - City:STORRS
Practice Address - State:CT
Practice Address - Zip Code:06268
Practice Address - Country:US
Practice Address - Phone:860-477-0497
Practice Address - Fax:860-477-0532
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000756101YP2500X
CT001179106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008002535Medicaid