Provider Demographics
NPI:1831131663
Name:HERTZOG, MELANIE PYKE (LCSW)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:PYKE
Last Name:HERTZOG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 POPLAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-6031
Mailing Address - Country:US
Mailing Address - Phone:607-763-2724
Mailing Address - Fax:
Practice Address - Street 1:114 CLINTON ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-2212
Practice Address - Country:US
Practice Address - Phone:607-763-2724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0331761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000025736OtherEXCELLUS (BC/BS)
NY07300033176Medicaid
NY000025736OtherEXCELLUS (BC/BS)