Provider Demographics
NPI:1639770142
Name:HAZLEWOOD, KAITLYN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:HAZLEWOOD
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:7204 ELLIS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-4302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7204 ELLIS RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-4302
Practice Address - Country:US
Practice Address - Phone:817-733-6208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113569235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist