Provider Demographics
NPI:1073249587
Name:HAZELET, CASEY DAWN
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:DAWN
Last Name:HAZELET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 LEXINGTON AVE APT B
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-4407
Mailing Address - Country:US
Mailing Address - Phone:234-575-1571
Mailing Address - Fax:
Practice Address - Street 1:512 CONTINENTAL DR APT 40
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-2469
Practice Address - Country:US
Practice Address - Phone:234-575-1571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0199300Medicaid