Provider Demographics
NPI:1174702245
Name:HAZEN, SHERILYN (SLP)
Entity type:Individual
Prefix:MS
First Name:SHERILYN
Middle Name:
Last Name:HAZEN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W KELTON LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-7930
Mailing Address - Country:US
Mailing Address - Phone:602-843-1070
Mailing Address - Fax:
Practice Address - Street 1:4650 W SWEETWATER AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1505
Practice Address - Country:US
Practice Address - Phone:602-347-2600
Practice Address - Fax:602-347-2709
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL0632251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ583436Medicaid