Healthcare Provider Details

I. General information

NPI: 1912603960
Provider Name (Legal Business Name): MARY HAZEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2023
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 NORTH RD
POUGHKEEPSIE NY
12601-1328
US

IV. Provider business mailing address

230 NORTH RD
POUGHKEEPSIE NY
12601-1328
US

V. Phone/Fax

Practice location:
  • Phone: 845-452-2728
  • Fax:
Mailing address:
  • Phone: 845-486-2738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number131106
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: