Provider Demographics
NPI:1841273711
Name:HAZEN, CHARLA JEANNE (LCSW)
Entity type:Individual
Prefix:
First Name:CHARLA
Middle Name:JEANNE
Last Name:HAZEN
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 1:10330 N MERIDIAN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1448 S A ST
Practice Address - Street 2:
Practice Address - City:ELWOOD
Practice Address - State:IN
Practice Address - Zip Code:46036-1903
Practice Address - Country:US
Practice Address - Phone:765-552-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2008-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000690A101YM0800X
IN34003501A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200270AMedicare PIN
S19175Medicare UPIN
IN220620C8Medicare PIN