Healthcare Provider Details

I. General information

NPI: 1164555306
Provider Name (Legal Business Name): KENNETH M. HAZLEWOOD LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 N 6TH ST
MONTAGUE CA
96064-8025
US

IV. Provider business mailing address

PO BOX 351
MONTAGUE CA
96064
US

V. Phone/Fax

Practice location:
  • Phone: 818-384-7103
  • Fax:
Mailing address:
  • Phone: 818-384-7103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number83241
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: