MEDICARE: MS. SHANA LEIGH HAZZARD LCSW

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	1041C0700X	Clinical Social Worker	32847	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	32847	OTHER	TX	TEXAS STATE BOARD OF SOCIAL WORK EXAMINERS

General Provider Information

NPI Number	:	1407003197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHANA LEIGH HAZZARD LCSW

Provider Business Mailing Address
First Line	:	3131 SANGUINET ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-5336
Country	:	US
Telephone Number	:	817-255-2612
Fax Number	:	817-735-4926

Provider Business Practice Location Address
First Line	:	3800 HULEN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-7276
Country	:	US
Telephone Number	:	817-255-2612
Fax Number	:	817-735-4926

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2008
Last Update Date	:	08/25/2008

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