Provider Demographics
NPI:1629785928
Name:HAINES, KRISTY
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:HAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 CENTER ST FRNT B
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-1519
Mailing Address - Country:US
Mailing Address - Phone:740-479-5135
Mailing Address - Fax:740-237-4870
Practice Address - Street 1:401 CENTER ST FRNT B
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-1519
Practice Address - Country:US
Practice Address - Phone:740-479-5135
Practice Address - Fax:740-237-4870
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator