Provider Demographics
NPI:1730221185
Name:HAZEN, GLORIA AMBER
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:AMBER
Last Name:HAZEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:AMBER
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1307 S ANN AVE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-1235
Mailing Address - Country:US
Mailing Address - Phone:816-719-6249
Mailing Address - Fax:
Practice Address - Street 1:2133 NW 13TH ST
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-7734
Practice Address - Country:US
Practice Address - Phone:816-224-0003
Practice Address - Fax:816-224-2199
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003014702235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist