Provider Demographics
NPI:1932852670
Name:HURT, KEIYANA
Entity Type:Individual
Prefix:
First Name:KEIYANA
Middle Name:
Last Name:HURT
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 1:2445 S 222ND ST APT G304
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-8845
Mailing Address - Country:US
Mailing Address - Phone:425-773-0457
Mailing Address - Fax:
Practice Address - Street 1:27023 164TH AVE SE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-8241
Practice Address - Country:US
Practice Address - Phone:253-639-7146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACBT.CB.61196684106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician