Healthcare Provider Details

I. General information

NPI: 1083345326
Provider Name (Legal Business Name): MS. KA'DAAR MARCELIZZ HAZELTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 S GRAND AVE
GLENDORA CA
91740-5000
US

IV. Provider business mailing address

1160 S GRAND AVE
GLENDORA CA
91740-5000
US

V. Phone/Fax

Practice location:
  • Phone: 626-842-7574
  • Fax:
Mailing address:
  • Phone: 626-842-7574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT136591
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAMFT136591
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: