Provider Demographics
NPI:1033121520
Name:HAZEN, LARRY KIRK (LCSW)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:KIRK
Last Name:HAZEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1887 RIVERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3084
Mailing Address - Country:US
Mailing Address - Phone:208-733-3730
Mailing Address - Fax:
Practice Address - Street 1:260 2ND AVE E
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6242
Practice Address - Country:US
Practice Address - Phone:208-732-0947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-269471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical