Healthcare Provider Details

I. General information

NPI: 1255764312
Provider Name (Legal Business Name): HAZEL WILCOX LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 SOUTH 12TH STREET
MAMMOTH SPRING AR
72554
US

IV. Provider business mailing address

PO BOX 1134
MAMMOTH SPRING AR
72554-1134
US

V. Phone/Fax

Practice location:
  • Phone: 870-625-0273
  • Fax: 870-625-0275
Mailing address:
  • Phone: 870-625-0273
  • Fax: 870-625-0275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7386-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: