Provider Demographics
NPI:1427539006
Name:IVERSON-HAYNES, TARA MONE'T
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MONE'T
Last Name:IVERSON-HAYNES
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 1:420 KENNEDY ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:66839-1120
Mailing Address - Country:US
Mailing Address - Phone:620-208-6480
Mailing Address - Fax:
Practice Address - Street 1:1200 GRAPHIC ARTS RD STE 100
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-6204
Practice Address - Country:US
Practice Address - Phone:620-481-7140
Practice Address - Fax:620-208-6488
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1514101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)