Provider Demographics
NPI:1619243284
Name:HAZLETT, BENJAMIN DON (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:DON
Last Name:HAZLETT
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 S MUSCOVY AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7748
Mailing Address - Country:US
Mailing Address - Phone:208-954-9427
Mailing Address - Fax:
Practice Address - Street 1:898 SW 4TH AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2627
Practice Address - Country:US
Practice Address - Phone:541-881-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP1932235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist