Provider Demographics
NPI:1063784411
Name:HAZELL, MORGANA (PSYD)
Entity type:Individual
Prefix:
First Name:MORGANA
Middle Name:
Last Name:HAZELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:120 HOSPITAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9238
Practice Address - Country:US
Practice Address - Phone:417-820-3128
Practice Address - Fax:417-820-8616
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011039220101YP2500X
MO2014001357103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1063784411Medicaid
MO1063784411Medicaid