Provider Demographics
NPI:1679330526
Name:HAYNIE, MALLORY KAY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:KAY
Last Name:HAYNIE
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 1:5950 PATRIOTS WAY
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2337
Mailing Address - Country:US
Mailing Address - Phone:517-648-6326
Mailing Address - Fax:
Practice Address - Street 1:4552 SPAHR AVE
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-1122
Practice Address - Country:US
Practice Address - Phone:517-884-1882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst