MEDICARE: EMMETT HAZELWOOD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1194028027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMETT HAZELWOOD

Provider Business Mailing Address
First Line	:	3576 ARLINGTON AVE STE 102
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3907
Country	:	US
Telephone Number	:	951-782-9577
Fax Number	:	951-782-9521

Provider Business Practice Location Address
First Line	:	3576 ARLINGTON AVE STE 102
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3907
Country	:	US
Telephone Number	:	951-782-9577
Fax Number	:	951-782-9521

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2010
Last Update Date	:	08/12/2011

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Directions to “ EMMETT HAZELWOOD ” Practice Location

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