Provider Demographics
NPI:1043953797
Name:HAZEN, MARY SHANNON (LMSW-U/S)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SHANNON
Last Name:HAZEN
Suffix:
Gender:F
Credentials:LMSW-U/S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 695
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-0695
Mailing Address - Country:US
Mailing Address - Phone:405-390-8131
Mailing Address - Fax:405-835-2253
Practice Address - Street 1:14625 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8728
Practice Address - Country:US
Practice Address - Phone:405-390-8131
Practice Address - Fax:405-835-2253
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8407-P104100000X
OK8407104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1881775211Medicaid