Healthcare Provider Details

I. General information

NPI: 1871892604
Provider Name (Legal Business Name): MICHELE RENEE HAZEN BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELE RENEE MULLENDORE BCBA

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14155 92 HWY
PLATTE CITY MO
64079-8907
US

IV. Provider business mailing address

20575 COUNTY ROAD DD
CAMDEN POINT MO
64018-9193
US

V. Phone/Fax

Practice location:
  • Phone: 816-608-1500
  • Fax:
Mailing address:
  • Phone: 816-304-6141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number2011004826
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2011004826
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: