Provider Demographics
NPI:1578008256
Name:HAZELTINE, GRACE E (PHD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:E
Last Name:HAZELTINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:E
Other - Last Name:HAZELTINE BARTMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4212 1/2 OVERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-3736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4212 1/2 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-3736
Practice Address - Country:US
Practice Address - Phone:323-553-2205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33148103T00000X
CAPSY33418103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01536011OtherMEDI-CAL