Provider Demographics
NPI:1639182686
Name:HAZELTON, BRYAN C (LCSW CASAC BCD)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:C
Last Name:HAZELTON
Suffix:
Gender:M
Credentials:LCSW CASAC BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N VILLAGE AVE
Mailing Address - Street 2:SUITE 32
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3767
Mailing Address - Country:US
Mailing Address - Phone:516-678-4079
Mailing Address - Fax:
Practice Address - Street 1:100 N VILLAGE AVE
Practice Address - Street 2:SUITE 32
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3767
Practice Address - Country:US
Practice Address - Phone:516-678-4079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR028215-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical