Provider Demographics
NPI:1063803310
Name:HURLEY, JOHN (LISW-SUPV)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HURLEY
Suffix:
Gender:M
Credentials:LISW-SUPV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-1578
Mailing Address - Country:US
Mailing Address - Phone:740-532-3534
Mailing Address - Fax:740-532-4859
Practice Address - Street 1:1408 CAMPBELL DR
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-2301
Practice Address - Country:US
Practice Address - Phone:740-534-9202
Practice Address - Fax:740-532-4777
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-0001632-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100417620Medicaid
OH0188218Medicaid
WV1063803310Medicaid
OHI-1000632-SUPVOtherSTATE LICENSE