Provider Demographics
NPI:1245782572
Name:VICKERS, HAZEL (BCBA #1-18-30040)
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:
Last Name:VICKERS
Suffix:
Gender:F
Credentials:BCBA #1-18-30040
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 REDHILL AVE
Mailing Address - Street 2:100
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 REDHILL AVE
Practice Address - Street 2:100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705
Practice Address - Country:US
Practice Address - Phone:949-267-0470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-03
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-30040103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst