MEDICARE: ANDREA LYNN HAZEN PHD

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	103TC0700X	Clinical Psychologist	18826	CA

General Provider Information

NPI Number	:	1588949507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA LYNN HAZEN PHD

Provider Business Mailing Address
First Line	:	3020 CHILDRENS WAY
Second Line	:	MC 5033
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4223
Country	:	US
Telephone Number	:	858-966-7703
Fax Number	:	858-966-7704

Provider Business Practice Location Address
First Line	:	3020 CHILDRENS WAY
Second Line	:	MC 5033
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4223
Country	:	US
Telephone Number	:	858-966-7703
Fax Number	:	858-966-7704

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

Provider Enumeration Date	:	10/21/2011
Last Update Date	:	10/21/2011

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