Provider Demographics
NPI:1629220751
Name:HAYNES, SHANETTE
Entity Type:Individual
Prefix:
First Name:SHANETTE
Middle Name:
Last Name: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:P.O. BOX 58755
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27658
Mailing Address - Country:US
Mailing Address - Phone:510-628-2999
Mailing Address - Fax:619-615-0705
Practice Address - Street 1:505 OBERLIN RD
Practice Address - Street 2:SUITE 230
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1327
Practice Address - Country:US
Practice Address - Phone:800-442-2762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2016-10-27
Deactivation Date:2011-04-26
Deactivation Code:
Reactivation Date:2012-08-13
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician