Provider Demographics
NPI:1407579071
Name:HINES, IRIS R
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:R
Last Name:HINES
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 1:711 ZITTEROUR DR
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-9269
Mailing Address - Country:US
Mailing Address - Phone:912-675-8922
Mailing Address - Fax:
Practice Address - Street 1:711 ZITTEROUR DR
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-9269
Practice Address - Country:US
Practice Address - Phone:912-675-8922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid