Healthcare Provider Details

I. General information

NPI: 1053359596
Provider Name (Legal Business Name): LESLIE E. HAZELWOOD L.P.C., L.C.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4561 S COMPTON AVE
SAINT LOUIS MO
63111-1554
US

IV. Provider business mailing address

501 NICOLET DR
GODFREY IL
62035-1937
US

V. Phone/Fax

Practice location:
  • Phone: 314-352-1770
  • Fax:
Mailing address:
  • Phone: 618-799-9070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2006012565
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: