Provider Demographics
NPI:1215413091
Name:HAZELTINE, MICHAEL B (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:B
Last Name:HAZELTINE
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-5715
Mailing Address - Country:US
Mailing Address - Phone:903-593-9141
Mailing Address - Fax:
Practice Address - Street 1:218 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5715
Practice Address - Country:US
Practice Address - Phone:903-593-9141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX79720101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health