Provider Demographics
NPI:1417172578
Name:HAYES, GWENETH MARTIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:GWENETH
Middle Name:MARTIN
Last Name:HAYES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7561 PETAL PL
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-1974
Mailing Address - Country:US
Mailing Address - Phone:678-755-4102
Mailing Address - Fax:
Practice Address - Street 1:1514 CLEVELAND AVE
Practice Address - Street 2:SUITE 84
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-6965
Practice Address - Country:US
Practice Address - Phone:678-904-2869
Practice Address - Fax:404-506-9820
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003076103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical