Provider Demographics
NPI:1598003394
Name:HAYNES, SUSAN BLACKWELDER (LCASA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BLACKWELDER
Last Name:HAYNES
Suffix:
Gender:F
Credentials:LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 CLANTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1309
Mailing Address - Country:US
Mailing Address - Phone:704-332-9001
Mailing Address - Fax:704-714-1182
Practice Address - Street 1:636 SIGNAL HILL DRIVE EXT
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4774
Practice Address - Country:US
Practice Address - Phone:704-871-2992
Practice Address - Fax:704-871-2994
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)