Provider Demographics
NPI:1952310435
Name:HAZEN, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:HAZEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 74 BOX 20709
Mailing Address - Street 2:
Mailing Address - City:EL PRADO
Mailing Address - State:NM
Mailing Address - Zip Code:87529-9507
Mailing Address - Country:US
Mailing Address - Phone:505-758-1494
Mailing Address - Fax:
Practice Address - Street 1:308 RIO LUCERO RD
Practice Address - Street 2:
Practice Address - City:EL PRADO
Practice Address - State:NM
Practice Address - Zip Code:87529-9507
Practice Address - Country:US
Practice Address - Phone:505-758-1494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0414106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG7297Medicaid
NM00JD84OtherBCBS PROVIDER NUMBER
NMNM102165OtherVALUE OPTIONS PROVIDER #