Provider Demographics
NPI:1659688513
Name:HAZEN, AMANDA J (OTR/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:HAZEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6245 WYNMOOR DR
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-9236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:159 W 1ST ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2045
Practice Address - Country:US
Practice Address - Phone:315-342-9575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011753-1174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator