Provider Demographics
NPI:1689039018
Name:HAYNES, KRYSTAL (CSW)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:HAYNES
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 S GRAND ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71202-6322
Mailing Address - Country:US
Mailing Address - Phone:318-324-5441
Mailing Address - Fax:318-324-5442
Practice Address - Street 1:4310 S GRAND ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202-6322
Practice Address - Country:US
Practice Address - Phone:318-324-5441
Practice Address - Fax:318-324-5442
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2115723Medicaid