Provider Demographics
NPI:1336323534
Name:HAYNES, BRADLEY B I (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:B
Last Name:HAYNES
Suffix:I
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111
Mailing Address - Country:US
Mailing Address - Phone:901-458-6291
Mailing Address - Fax:901-323-4848
Practice Address - Street 1:3950 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111
Practice Address - Country:US
Practice Address - Phone:901-458-6291
Practice Address - Fax:901-323-4848
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2810103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist