Provider Demographics
NPI:1730282807
Name:HAZEL, ENRIQUE (PT)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:HAZEL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 LA POSADA DR STE 230
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752-3842
Mailing Address - Country:US
Mailing Address - Phone:512-284-7192
Mailing Address - Fax:512-284-7203
Practice Address - Street 1:1033 LA POSADA DR
Practice Address - Street 2:SUITE 308
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-3842
Practice Address - Country:US
Practice Address - Phone:512-284-7202
Practice Address - Fax:512-284-7203
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109849225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00X977OtherGROUP PTAN
109849OtherOT LICENSE
TX212434901Medicaid