Provider Demographics
NPI:1083258792
Name:HAYNES, MICHAELA
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:HAYNES
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 1:1400 HI LINE DR APT 2216
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75207-3453
Mailing Address - Country:US
Mailing Address - Phone:972-404-6233
Mailing Address - Fax:
Practice Address - Street 1:1400 HI LINE DR APT 2216
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75207-3453
Practice Address - Country:US
Practice Address - Phone:972-404-6233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79433101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional