Provider Demographics
NPI:1457383556
Name:HURST, AUSTIN GOLLMER (PHD, MA)
Entity Type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:GOLLMER
Last Name:HURST
Suffix:
Gender:M
Credentials:PHD, MA
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:NONE
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:954 RISA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3418
Mailing Address - Country:US
Mailing Address - Phone:925-284-0691
Mailing Address - Fax:925-283-2381
Practice Address - Street 1:954 RISA RD
Practice Address - Street 2:SUITE A
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3418
Practice Address - Country:US
Practice Address - Phone:925-284-0691
Practice Address - Fax:925-283-2381
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4909103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL49090Medicaid
CA0PL49090Medicare ID - Type Unspecified