Provider Demographics
NPI:1578391132
Name:HAZEN, ALLEN REVARD
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:REVARD
Last Name:HAZEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 WIDGEON CT
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-8971
Mailing Address - Country:US
Mailing Address - Phone:406-249-4405
Mailing Address - Fax:
Practice Address - Street 1:723 5TH AVE E # B-18
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-5321
Practice Address - Country:US
Practice Address - Phone:406-249-4405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health