Healthcare Provider Details

I. General information

NPI: 1235782004
Provider Name (Legal Business Name): SHANIQUA CARMEN HAZLIP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELIZABETH PL
DAYTON OH
45417-3445
US

IV. Provider business mailing address

807 MERRY JOHN DR
MIAMISBURG OH
45342-2043
US

V. Phone/Fax

Practice location:
  • Phone: 937-813-1737
  • Fax:
Mailing address:
  • Phone: 937-369-5910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number170841
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: