Basic Information
| Provider Information | |||||||||
| NPI: | 1548230808 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | HAZELTON | ||||||||
| FirstName: | TRACI | ||||||||
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| Credential: | PT, ATC, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 181 PATRICIA GENOVA DRIVE | ||||||||
| Address2: | EASTERN REHABILITATION NETWORK 5TH FLOOR | ||||||||
| City: | NEWINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606675449 | ||||||||
| FaxNumber: | 8606678416 | ||||||||
| Practice Location | |||||||||
| Address1: | 445 SOUTH MAIN STREET | ||||||||
| Address2: | EASTERN REHABILITATION NETWORK 5TH FLOOR | ||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605218800 | ||||||||
| FaxNumber: | 8605218801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 006312 | CT | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2255A2300X | 000301 | CT | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.