Provider Demographics
NPI:1245633775
Name:HAZELWOOD, REBECCA JORDAN (MED, CCC-SLP, BCSS)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:JORDAN
Last Name:HAZELWOOD
Suffix:
Gender:F
Credentials:MED, CCC-SLP, BCSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151B RUTLEDGE AVE
Mailing Address - Street 2:MSC 962
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-8903
Mailing Address - Country:US
Mailing Address - Phone:843-792-7162
Mailing Address - Fax:
Practice Address - Street 1:109 BEE ST
Practice Address - Street 2:RALPH H. JOHNSON VA MEDICAL CENTER
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-5703
Practice Address - Country:US
Practice Address - Phone:843-789-6653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5065235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist