Provider Demographics
NPI:1134628514
Name:HYATT, MICHELLE (MA, LPCA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HYATT
Suffix:
Gender:F
Credentials:MA, LPCA
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:HYATT
Other - Last Name:BAHNEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LPCA
Mailing Address - Street 1:1539 TIANA WAY
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-7605
Mailing Address - Country:US
Mailing Address - Phone:803-370-8852
Mailing Address - Fax:
Practice Address - Street 1:1539 TIANA WAY
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-7605
Practice Address - Country:US
Practice Address - Phone:803-307-4647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6900101Y00000X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1134628514Medicaid