Provider Demographics
NPI:1649599622
Name:HAZEYAMA, DIANE (MS)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:HAZEYAMA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2351
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES PENINSULA
Mailing Address - State:CA
Mailing Address - Zip Code:90274-8351
Mailing Address - Country:US
Mailing Address - Phone:310-547-7954
Mailing Address - Fax:
Practice Address - Street 1:21515 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-6501
Practice Address - Country:US
Practice Address - Phone:510-345-4379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-31
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT121946106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist