Provider Demographics
NPI:1992979421
Name:HAZLETT, LISA M (SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:HAZLETT
Suffix:
Gender:F
Credentials:SLP
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 1807
Mailing Address - Street 2:
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-4807
Mailing Address - Country:US
Mailing Address - Phone:276-386-2424
Mailing Address - Fax:276-386-1446
Practice Address - Street 1:195 KANE STREET
Practice Address - Street 2:
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251
Practice Address - Country:US
Practice Address - Phone:276-386-2424
Practice Address - Fax:276-386-1446
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004203235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA496634Medicare PIN