Healthcare Provider Details

I. General information

NPI: 1326376104
Provider Name (Legal Business Name): WILLIAM BURTON HAZEL III LCSW,LADC,BCD,AADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2009
Last Update Date: 08/18/2024
Certification Date: 08/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5142
APO AP
96368-5142
US

IV. Provider business mailing address

PO BOX 290881
YIGO GU
96929-3044
US

V. Phone/Fax

Practice location:
  • Phone: 315-630-4780
  • Fax:
Mailing address:
  • Phone: 671-747-4353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000589
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSWE-006
License Number StateGU
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number006619
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: