Provider Demographics
NPI:1154506137
Name:HAYNES, GLENDA FAYE (BS)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:FAYE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W GORE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-3710
Mailing Address - Country:US
Mailing Address - Phone:580-357-8166
Mailing Address - Fax:
Practice Address - Street 1:411 W GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-3710
Practice Address - Country:US
Practice Address - Phone:580-357-8166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)