Healthcare Provider Details

I. General information

NPI: 1124037213
Provider Name (Legal Business Name): ANN PETESCH HAZZARD PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 JESSE HILL JR DR SE
ATLANTA GA
30303-3032
US

IV. Provider business mailing address

49 JESSE HILL JR DR SE
ATLANTA GA
30303-3049
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-4390
  • Fax: 404-616-6795
Mailing address:
  • Phone: 404-616-4875
  • Fax: 404-616-6657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number000803
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: