Provider Demographics
NPI:1548230808
Name:HAZELTON, TRACI (PT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:HAZELTON
Suffix:
Gender:F
Credentials:PT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 PATRICIA GENOVA DRIVE
Mailing Address - Street 2:EASTERN REHABILITATION NETWORK 5TH FLOOR
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111
Mailing Address - Country:US
Mailing Address - Phone:860-667-5449
Mailing Address - Fax:860-667-8416
Practice Address - Street 1:445 SOUTH MAIN STREET
Practice Address - Street 2:EASTERN REHABILITATION NETWORK 5TH FLOOR
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110
Practice Address - Country:US
Practice Address - Phone:860-521-8800
Practice Address - Fax:860-521-8801
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006312225100000X
CT0003012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer