Healthcare Provider Details

I. General information

NPI: 1548273428
Provider Name (Legal Business Name): MARK HAZELRIGG PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 PATTERSON RD
DURHAM NC
27704-8508
US

IV. Provider business mailing address

209 PATTERSON RD
DURHAM NC
27704-8508
US

V. Phone/Fax

Practice location:
  • Phone: 919-606-0563
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number1602
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: