Provider Demographics
NPI:1184208563
Name:HAZEL, JUSTIN REED (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:REED
Last Name:HAZEL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 E MAIN ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-8696
Mailing Address - Country:US
Mailing Address - Phone:270-699-9503
Mailing Address - Fax:270-699-3804
Practice Address - Street 1:703 E MAIN ST UNIT 1
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-8696
Practice Address - Country:US
Practice Address - Phone:270-699-9503
Practice Address - Fax:270-699-3804
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP2021023225100000X
KY008374225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist