Provider Demographics
NPI:1790541118
Name:HAZEL, KIMBERLY DAWN (ALC)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:HAZEL
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 CHAREST RD
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35670-3315
Mailing Address - Country:US
Mailing Address - Phone:256-565-0992
Mailing Address - Fax:
Practice Address - Street 1:185 CHATEAU DR SW STE 102
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-7415
Practice Address - Country:US
Practice Address - Phone:256-489-1583
Practice Address - Fax:256-489-1595
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC04801101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty