Healthcare Provider Details

I. General information

NPI: 1336943448
Provider Name (Legal Business Name): MICHAEL HAZEL LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 COLORADO AVE
PUEBLO CO
81004-2005
US

IV. Provider business mailing address

325 W PITKIN AVE
PUEBLO CO
81004-1841
US

V. Phone/Fax

Practice location:
  • Phone: 719-948-7120
  • Fax:
Mailing address:
  • Phone: 913-558-5194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2961770
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: