Provider Demographics
NPI:1891855136
Name:HAZEN, NEAL ALLEN (PT, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:NEAL
Middle Name:ALLEN
Last Name:HAZEN
Suffix:
Gender:M
Credentials:PT, ATC, LAT
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 6890
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47719-0890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3415 W FOX RIDGE LN
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5204
Practice Address - Country:US
Practice Address - Phone:765-282-3486
Practice Address - Fax:765-282-5637
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002055A225100000X
IN36000116A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200816790Medicaid
IN000000386711OtherANTHEM