Provider Demographics
NPI:1871892604
Name:HAZEN, MICHELE RENEE (BCBA)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:RENEE
Last Name:HAZEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:RENEE
Other - Last Name:MULLENDORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:20575 COUNTY ROAD DD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN POINT
Mailing Address - State:MO
Mailing Address - Zip Code:64018-9193
Mailing Address - Country:US
Mailing Address - Phone:816-304-6141
Mailing Address - Fax:
Practice Address - Street 1:14155 92 HWY
Practice Address - Street 2:
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-8907
Practice Address - Country:US
Practice Address - Phone:816-608-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-18
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011004826103K00000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities