Provider Demographics
NPI:1699055715
Name:HYATT, TINA M
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
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 1:457 MOUNT OLIVET CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:FAWN GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17321-9611
Mailing Address - Country:US
Mailing Address - Phone:443-717-2539
Mailing Address - Fax:
Practice Address - Street 1:200 BOOTH ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5657
Practice Address - Country:US
Practice Address - Phone:410-996-5104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-20
Last Update Date:2011-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG11102101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health