Provider Demographics
NPI:1548704349
Name:HAZLEHURST, KELSEA
Entity type:Individual
Prefix:
First Name:KELSEA
Middle Name:
Last Name:HAZLEHURST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 EDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-1047
Mailing Address - Country:US
Mailing Address - Phone:206-419-6590
Mailing Address - Fax:
Practice Address - Street 1:528 EDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-1047
Practice Address - Country:US
Practice Address - Phone:206-419-6590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-13
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292412225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist