Provider Demographics
NPI:1326799040
Name:HAYWORTH, SHAMIKA DENISE
Entity Type:Individual
Prefix:
First Name:SHAMIKA
Middle Name:DENISE
Last Name:HAYWORTH
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 1:18921 COFFINBERRY BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44126-1601
Mailing Address - Country:US
Mailing Address - Phone:216-225-9799
Mailing Address - Fax:
Practice Address - Street 1:6143 GOLDENROD LN
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-4371
Practice Address - Country:US
Practice Address - Phone:317-362-4227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YA0400X, 103K00000X, 171W00000X, 172V00000X, 376K00000X, 385H00000X, 385HR2055X, 175T00000X
106S00000X, 385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171W00000XOther Service ProvidersContractor
No172V00000XOther Service ProvidersCommunity Health Worker
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
No385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child