Provider Demographics
NPI:1164555306
Name:HAZLEWOOD, KENNETH M (LMFT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:M
Last Name:HAZLEWOOD
Suffix:
Gender:M
Credentials:LMFT
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 351
Mailing Address - Street 2:
Mailing Address - City:MONTAGUE
Mailing Address - State:CA
Mailing Address - Zip Code:96064
Mailing Address - Country:US
Mailing Address - Phone:818-384-7103
Mailing Address - Fax:
Practice Address - Street 1:251 N 6TH ST
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:CA
Practice Address - Zip Code:96064-8025
Practice Address - Country:US
Practice Address - Phone:818-384-7103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83241106H00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist