Provider Demographics
NPI:1033411400
Name:HAZELL, GRACE KATHRYN (COTA)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:KATHRYN
Last Name:HAZELL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MISS
Other - First Name:GRACE
Other - Middle Name:KATHRYN
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:6808 64TH PL NE UNIT A
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-5313
Mailing Address - Country:US
Mailing Address - Phone:719-433-0192
Mailing Address - Fax:
Practice Address - Street 1:920 S CHELTON RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-2311
Practice Address - Country:US
Practice Address - Phone:719-473-1283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32000654A224Z00000X
WAOC 60414053224Z00000X
COOTA 0000532224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant