Healthcare Provider Details

I. General information

NPI: 1780231233
Provider Name (Legal Business Name): NICOLE RENEE HAZEL BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5896 CROSSCUT LN
NOBLESVILLE IN
46062-9672
US

IV. Provider business mailing address

5896 CROSSCUT LN
NOBLESVILLE IN
46062-9672
US

V. Phone/Fax

Practice location:
  • Phone: 317-200-0046
  • Fax:
Mailing address:
  • Phone: 317-200-0046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: