Provider Demographics
NPI:1114653672
Name:HAYNES, TRACY L
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:HAYNES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 LODGE AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43609-2911
Mailing Address - Country:US
Mailing Address - Phone:419-787-0532
Mailing Address - Fax:
Practice Address - Street 1:500 MADISON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-1222
Practice Address - Country:US
Practice Address - Phone:567-312-8700
Practice Address - Fax:567-312-8793
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH106S00000X, 251B00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251B00000XAgenciesCase Management