Provider Demographics
NPI:1275643983
Name:HAZELWOOD, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HAZELWOOD
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:RR 6 BOX 239A
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-9247
Mailing Address - Country:US
Mailing Address - Phone:918-420-5845
Mailing Address - Fax:
Practice Address - Street 1:221 E COMANCHE AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5845
Practice Address - Country:US
Practice Address - Phone:918-423-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK499OtherLICENSE