Provider Demographics
NPI:1902102759
Name:HAZUKA, MICHELLE RENEE (MS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:HAZUKA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E498 NORSKE RD
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54945-9298
Mailing Address - Country:US
Mailing Address - Phone:715-212-6209
Mailing Address - Fax:715-848-5008
Practice Address - Street 1:E498 NORSKE RD
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:WI
Practice Address - Zip Code:54945-9298
Practice Address - Country:US
Practice Address - Phone:715-677-4035
Practice Address - Fax:715-848-5008
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6279-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional