Provider Demographics
NPI:1164548236
Name:HAYNES FAMILY OF PROGRAMS
Entity Type:Organization
Organization Name:HAYNES FAMILY OF PROGRAMS
Other - Org Name:LEROY HAYNES CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAYDECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-593-2581
Mailing Address - Street 1:1350 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-5201
Mailing Address - Country:US
Mailing Address - Phone:909-593-2581
Mailing Address - Fax:909-596-3567
Practice Address - Street 1:1350 3RD ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-5201
Practice Address - Country:US
Practice Address - Phone:909-593-2581
Practice Address - Fax:909-596-3567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CA191501972320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7565AOtherOUTPATIENT MENTAL HEALTH