Provider Demographics
NPI:1639495740
Name:HURST, MICHAEL REYNOLDS (MS, LADAC, CEAP, SAP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:REYNOLDS
Last Name:HURST
Suffix:
Gender:M
Credentials:MS, LADAC, CEAP, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 SIERRA BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-0728
Mailing Address - Country:US
Mailing Address - Phone:575-636-5260
Mailing Address - Fax:575-524-1454
Practice Address - Street 1:1990 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3172
Practice Address - Country:US
Practice Address - Phone:575-636-5260
Practice Address - Fax:575-524-1454
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-14
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0128791101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)