Provider Demographics
NPI:1508317942
Name:ZETINO, HAZEL
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:
Last Name:ZETINO
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 1:401 GRAND AVE STE 380
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-5054
Mailing Address - Country:US
Mailing Address - Phone:510-330-6967
Mailing Address - Fax:
Practice Address - Street 1:401 GRAND AVE STE 380
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-5054
Practice Address - Country:US
Practice Address - Phone:510-330-6967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118757101YM0800X
106H00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program