Provider Demographics
NPI:1467481309
Name:HAYNES, TERESA MICHELLE (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:MICHELLE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1989
Mailing Address - Street 2:
Mailing Address - City:LEADVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80461-1989
Mailing Address - Country:US
Mailing Address - Phone:970-389-0621
Mailing Address - Fax:
Practice Address - Street 1:LEADVILLE PROFESSIONAL BUILDING
Practice Address - Street 2:735 HWY 24 SOUTH, SUITE B
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461
Practice Address - Country:US
Practice Address - Phone:970-389-0621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4020101YP2500X
CO3965103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional