Provider Demographics
NPI:1770809063
Name:HAZLEWOOD, TINA (MS)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:HAZLEWOOD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 POPLAR AVE STE 411
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4434
Mailing Address - Country:US
Mailing Address - Phone:901-517-1164
Mailing Address - Fax:901-284-0570
Practice Address - Street 1:4646 POPLAR AVE STE 411
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4434
Practice Address - Country:US
Practice Address - Phone:901-517-1164
Practice Address - Fax:901-284-0570
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional