Provider Demographics
NPI:1083309413
Name:HAZELTINE, MELODY (PTA)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:HAZELTINE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6720 SANBORN RD
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-9553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1515 BROOKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-8210
Practice Address - Country:US
Practice Address - Phone:440-226-8869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant