Provider Demographics
NPI:1073533667
Name:HAZLETON, DEEDRA (PT)
Entity Type:Individual
Prefix:
First Name:DEEDRA
Middle Name:
Last Name:HAZLETON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 MONTCLAIR DR
Mailing Address - Street 2:SP87
Mailing Address - City:BIG BEAR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92314-9728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41945 BIG BEAR BLVD
Practice Address - Street 2:209
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315
Practice Address - Country:US
Practice Address - Phone:909-866-6200
Practice Address - Fax:909-866-6111
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11085225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist