Provider Demographics
NPI:1073110391
Name:HLISTA, MELANIE
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:
Last Name:HLISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MELANIE
Other - Middle Name:LYNN
Other - Last Name:RASH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:381 CONESTOGA DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-1559
Mailing Address - Country:US
Mailing Address - Phone:219-928-8001
Mailing Address - Fax:
Practice Address - Street 1:2775 VILLAGE PT
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-0099
Practice Address - Country:US
Practice Address - Phone:219-928-8001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002595A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant