Provider Demographics
NPI:1891160388
Name:HYATT, MELODY
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:HYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2039 MORIAH RD
Mailing Address - Street 2:
Mailing Address - City:MORIAH
Mailing Address - State:NY
Mailing Address - Zip Code:12960-0000
Mailing Address - Country:US
Mailing Address - Phone:518-546-7008
Mailing Address - Fax:518-882-0282
Practice Address - Street 1:1717 FRONT STREET
Practice Address - Street 2:
Practice Address - City:KEESVILLE
Practice Address - State:NY
Practice Address - Zip Code:12944-0000
Practice Address - Country:US
Practice Address - Phone:518-834-0282
Practice Address - Fax:518-882-0282
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000974-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency