Provider Demographics
NPI:1801196027
Name:HAZELWOOD, LISA LOUISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:LOUISE
Last Name:HAZELWOOD
Suffix:
Gender:F
Credentials:PHD
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 5488
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91117-0488
Mailing Address - Country:US
Mailing Address - Phone:806-535-5893
Mailing Address - Fax:626-737-8384
Practice Address - Street 1:9500 ETIWANDA AVE., WEST VALLEY DETENTION CENTER
Practice Address - Street 2:ATTN: MEDICAL SRVCS/LIBERTY ROC
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739
Practice Address - Country:US
Practice Address - Phone:909-463-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2013-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23776103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical