Provider Demographics
NPI:1306223540
Name:HAZLETT, FREDERICK (LMT)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:HAZLETT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 CONKLIN RD
Mailing Address - Street 2:
Mailing Address - City:CONKLIN
Mailing Address - State:NY
Mailing Address - Zip Code:13748-1405
Mailing Address - Country:US
Mailing Address - Phone:607-775-0178
Mailing Address - Fax:
Practice Address - Street 1:1213 CONKLIN RD
Practice Address - Street 2:
Practice Address - City:CONKLIN
Practice Address - State:NY
Practice Address - Zip Code:13748-1405
Practice Address - Country:US
Practice Address - Phone:607-775-0178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012761-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist