Provider Demographics
NPI:1831217876
Name:HAZELTON, ELLYN ANN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:ELLYN
Middle Name:ANN
Last Name:HAZELTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10280 GAUL WAY
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-1717
Mailing Address - Country:US
Mailing Address - Phone:619-660-7387
Mailing Address - Fax:
Practice Address - Street 1:10992 SAN DIEGO MISSION RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2444
Practice Address - Country:US
Practice Address - Phone:619-641-4100
Practice Address - Fax:619-641-4111
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS155251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical