Provider Demographics
NPI:1336157379
Name:HURST, SUSAN I (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:I
Last Name:HURST
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 EDGEWOOD LOOP
Mailing Address - Street 2:
Mailing Address - City:ANGELS CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95222-8212
Mailing Address - Country:US
Mailing Address - Phone:209-990-9525
Mailing Address - Fax:
Practice Address - Street 1:245 TOM BELL RD
Practice Address - Street 2:STE C
Practice Address - City:MURPHYS
Practice Address - State:CA
Practice Address - Zip Code:95247-9585
Practice Address - Country:US
Practice Address - Phone:714-993-1664
Practice Address - Fax:714-993-1079
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC19508106H00000X
CAPSY14337103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP14337Medicare ID - Type Unspecified