Provider Demographics
NPI:1699034975
Name:HURSE, NATHANIEL W (LADC #301333)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:W
Last Name:HURSE
Suffix:
Gender:M
Credentials:LADC #301333
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7508
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-0508
Mailing Address - Country:US
Mailing Address - Phone:612-203-9809
Mailing Address - Fax:612-879-3604
Practice Address - Street 1:8557 WYOMING AVE N STE 6
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445-1847
Practice Address - Country:US
Practice Address - Phone:612-203-9980
Practice Address - Fax:612-879-3604
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301333101YA0400X
MN221451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical