Provider Demographics
NPI:1780265090
Name:HURST, CARLY ANN
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ANN
Last Name:HURST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-2120
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:OGLESBY
Practice Address - State:IL
Practice Address - Zip Code:61348-1367
Practice Address - Country:US
Practice Address - Phone:815-200-8830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242006156235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist