MEDICARE: HAZEL MACKEY CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180-00384	IL
2	101YP2500X	Professional Counselor		IL
3	1041C0700X	Clinical Social Worker		IL
4	106H00000X	Marriage & Family Therapist		IL
5	1041C0700X	Clinical Social Worker		IL

General Provider Information

NPI Number	:	1306992938
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAZEL MACKEY CENTER

Provider Business Mailing Address
First Line	:	1128 S 5TH ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-2314
Country	:	US
Telephone Number	:	217-544-0388
Fax Number	:	217-544-0391

Provider Business Practice Location Address
First Line	:	1128 S 5TH ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-2314
Country	:	US
Telephone Number	:	217-544-0388
Fax Number	:	217-544-0391

Authorized Official
Title or Position	:	CHIEF FISCAL OFFICER
Name	:	MR. BARNEY M BRUZETTI
Credential	:	CPA
Telephone Number	:	217-544-0388

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	09/11/2025

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Directions to “HAZEL MACKEY CENTER ” Practice Location

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