Provider Demographics
NPI:1679854848
Name:HAZELWOOD, CHANDA L
Entity Type:Individual
Prefix:
First Name:CHANDA
Middle Name:L
Last Name:HAZELWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 ABBINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-4931
Mailing Address - Country:US
Mailing Address - Phone:702-772-9346
Mailing Address - Fax:702-446-8465
Practice Address - Street 1:4760 S PECOS RD # 103-25
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5828
Practice Address - Country:US
Practice Address - Phone:702-772-9346
Practice Address - Fax:702-446-8465
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005054570Medicaid