Provider Demographics
NPI:1811194707
Name:HART, DOREEN MARIE HAZEL (LMT, CST)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:MARIE HAZEL
Last Name:HART
Suffix:
Gender:F
Credentials:LMT, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15040 21 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-8108
Mailing Address - Country:US
Mailing Address - Phone:269-986-1789
Mailing Address - Fax:269-781-1979
Practice Address - Street 1:15040 21 MILE RD
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-8108
Practice Address - Country:US
Practice Address - Phone:269-986-1789
Practice Address - Fax:269-781-1979
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor