Provider Demographics
NPI:1609012582
Name:BASA, HAZEL NALYN (COTA)
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:NALYN
Last Name:BASA
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 N WABASH RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1300
Mailing Address - Country:US
Mailing Address - Phone:765-651-3229
Mailing Address - Fax:
Practice Address - Street 1:2237 ENGLE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-1404
Practice Address - Country:US
Practice Address - Phone:260-747-2353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-26
Last Update Date:2008-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001575A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant