Provider Demographics
NPI:1629425442
Name:HAZEL, DIANA GROSS (LPC, MT-BC)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:GROSS
Last Name:HAZEL
Suffix:
Gender:F
Credentials:LPC, MT-BC
Other - Prefix:MISS
Other - First Name:DIANA
Other - Middle Name:LYNN
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MT-BC
Mailing Address - Street 1:25 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BOYERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19512-1405
Mailing Address - Country:US
Mailing Address - Phone:484-333-5164
Mailing Address - Fax:
Practice Address - Street 1:25 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BOYERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19512-1405
Practice Address - Country:US
Practice Address - Phone:484-333-5164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-22
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA10546225A00000X
PAPC016087101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist