Provider Demographics
NPI:1376778431
Name:HAYLOCK-PETERS, CYNTHIA
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:
Last Name:HAYLOCK-PETERS
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 1:18045 W ACAPULCO LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-8733
Mailing Address - Country:US
Mailing Address - Phone:623-691-4718
Mailing Address - Fax:623-691-5924
Practice Address - Street 1:3401 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-4517
Practice Address - Country:US
Practice Address - Phone:623-691-4085
Practice Address - Fax:623-691-5924
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3694642103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3694642Medicaid