Provider Demographics
NPI:1205938156
Name:CAMAGONG, HAZEL T (SLP)
Entity type:Individual
Prefix:
First Name:HAZEL
Middle Name:T
Last Name:CAMAGONG
Suffix:
Gender:F
Credentials:SLP
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 8419
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-8087
Mailing Address - Country:US
Mailing Address - Phone:228-388-5714
Mailing Address - Fax:228-388-0017
Practice Address - Street 1:394 COURTHOUSE RD
Practice Address - Street 2:SUITE B
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1865
Practice Address - Country:US
Practice Address - Phone:228-896-1189
Practice Address - Fax:228-896-9989
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2478235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015077Medicaid
MS1033218524OtherGROUP NPI
MSC02726Medicare PIN