Provider Demographics
NPI:1669896486
Name:HAZELTINE, THERESE B (LMT)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:B
Last Name:HAZELTINE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7954 ADEN LOOP
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-2724
Mailing Address - Country:US
Mailing Address - Phone:727-271-4383
Mailing Address - Fax:
Practice Address - Street 1:3795 ALT 19 # A1
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-1400
Practice Address - Country:US
Practice Address - Phone:727-271-4383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA46785175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath