Provider Demographics
NPI:1861409583
Name:HAZELTINE, PERRY (PHD)
Entity type:Individual
Prefix:
First Name:PERRY
Middle Name:
Last Name:HAZELTINE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 N DUKE ST
Mailing Address - Street 2:STE 1
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2779
Mailing Address - Country:US
Mailing Address - Phone:717-875-8993
Mailing Address - Fax:
Practice Address - Street 1:243 N DUKE ST
Practice Address - Street 2:STE 1
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2779
Practice Address - Country:US
Practice Address - Phone:717-875-8993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007197L103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02153901OtherCAPITALBLUECROSS
PA214037OtherVALUEOPTIONS
PA842925OtherHIGHMARK
PA250533OtherALLIANCE
PA620005401OtherRRMEDICARE
PA250533OtherALLIANCE
PA842925G09Medicare ID - Type UnspecifiedMEDICARE