Provider Demographics
NPI:1134686066
Name:HAYES, ANITA MARIE
Entity Type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:MARIE
Last Name:HAYES
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ANITA
Other - Middle Name:M
Other - Last Name:HAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:383 W TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IL
Mailing Address - Zip Code:62692-1066
Mailing Address - Country:US
Mailing Address - Phone:217-556-5001
Mailing Address - Fax:
Practice Address - Street 1:383 W TEMPLE ST
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IL
Practice Address - Zip Code:62692-1066
Practice Address - Country:US
Practice Address - Phone:217-556-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL000000Medicaid