Healthcare Provider Details

I. General information

NPI: 1780969436
Provider Name (Legal Business Name): MR. GARY LEE HYATT II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W PARK AVE
CHAMPAIGN IL
61820-3929
US

IV. Provider business mailing address

406 N RANDOLPH ST #201
CHAMPAIGN IL
61820-8616
US

V. Phone/Fax

Practice location:
  • Phone: 217-373-2430
  • Fax:
Mailing address:
  • Phone: 903-456-4927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: