Provider Demographics
NPI:1447514153
Name:HAZELL, CLIVE GARRAD (PHD, DN)
Entity type:Individual
Prefix:DR
First Name:CLIVE
Middle Name:GARRAD
Last Name:HAZELL
Suffix:
Gender:M
Credentials:PHD, DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3324 N KOSTNER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-4513
Mailing Address - Country:US
Mailing Address - Phone:773-726-1952
Mailing Address - Fax:
Practice Address - Street 1:3324 N KOSTNER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-4513
Practice Address - Country:US
Practice Address - Phone:773-726-1952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180003932103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling