Provider Demographics
NPI:1669751350
Name:HAZEN, LOIS JEAN (MT)
Entity type:Individual
Prefix:
First Name:LOIS
Middle Name:JEAN
Last Name:HAZEN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-3017
Mailing Address - Country:US
Mailing Address - Phone:605-624-6732
Mailing Address - Fax:605-624-6732
Practice Address - Street 1:216 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-3017
Practice Address - Country:US
Practice Address - Phone:605-624-6732
Practice Address - Fax:605-624-6732
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD551225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist