Provider Demographics
NPI:1518985365
Name:HAINES, HEATHER LEE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEE
Last Name:HAINES
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LEE
Other - Last Name:HAINES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:420 HWY 54 WEST
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615
Mailing Address - Country:US
Mailing Address - Phone:715-284-4301
Mailing Address - Fax:715-284-7713
Practice Address - Street 1:420 HWY 54 WEST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615
Practice Address - Country:US
Practice Address - Phone:715-284-4301
Practice Address - Fax:715-284-7713
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3456-1251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40947400Medicaid