Provider Demographics
NPI:1134244338
Name:HAZEL, JOE WAYNE (LCAS)
Entity type:Individual
Prefix:MR
First Name:JOE
Middle Name:WAYNE
Last Name:HAZEL
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 TRAWICK RD
Mailing Address - Street 2:UNIT 6
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-4600
Mailing Address - Country:US
Mailing Address - Phone:919-452-0738
Mailing Address - Fax:919-329-9848
Practice Address - Street 1:2940 TRAWICK RD
Practice Address - Street 2:UNIT 6
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-4600
Practice Address - Country:US
Practice Address - Phone:919-452-0738
Practice Address - Fax:919-329-9848
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC596101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111839Medicaid