Provider Demographics
NPI:1336652346
Name:HAZELWOOD, AUDREY C (MED, BCBA-LBA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:C
Last Name:HAZELWOOD
Suffix:
Gender:F
Credentials:MED, BCBA-LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3441 FORT CAMPBELL BLVD STE F3
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-6684
Mailing Address - Country:US
Mailing Address - Phone:931-449-0063
Mailing Address - Fax:931-896-2737
Practice Address - Street 1:3441 FORT CAMPBELL BLVD STE F3
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-6684
Practice Address - Country:US
Practice Address - Phone:931-449-0063
Practice Address - Fax:931-896-2737
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-17-28664103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1-17-28664OtherBEHAVIOR ANALYSIS CERTIFICATION BOARD