Provider Demographics
NPI:1083186431
Name:MOON, HAZEL (LPC)
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:LPC
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 2066
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-2066
Mailing Address - Country:US
Mailing Address - Phone:479-219-7299
Mailing Address - Fax:
Practice Address - Street 1:400 W CAPITOL AVE STE 1700
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-3438
Practice Address - Country:US
Practice Address - Phone:646-453-6777
Practice Address - Fax:917-525-4985
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP2202000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional