Provider Demographics
NPI:1164025839
Name:HAZEN, TENNA DAWN
Entity Type:Individual
Prefix:
First Name:TENNA
Middle Name:DAWN
Last Name:HAZEN
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 1:122 E LIEBER ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2617
Mailing Address - Country:US
Mailing Address - Phone:660-582-7113
Mailing Address - Fax:
Practice Address - Street 1:122 E LIEBER ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2617
Practice Address - Country:US
Practice Address - Phone:660-582-7113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12045045103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst