Provider Demographics
NPI:1235693292
Name:HAZEN, VIRGINIA BAKER
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:BAKER
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 1:308 CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2506
Mailing Address - Country:US
Mailing Address - Phone:404-308-8548
Mailing Address - Fax:
Practice Address - Street 1:308 CLAIREMONT AVENUE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2506
Practice Address - Country:US
Practice Address - Phone:404-308-8548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006596101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health