Provider Demographics
NPI:1689356792
Name:HAYNES, COURTNEY KIANA (IMH 24252)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:KIANA
Last Name:HAYNES
Suffix:
Gender:F
Credentials:IMH 24252
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 CENTENARY LOOP APT 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1510
Mailing Address - Country:US
Mailing Address - Phone:904-250-2436
Mailing Address - Fax:
Practice Address - Street 1:310 WAYMONT CT STE 100
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3475
Practice Address - Country:US
Practice Address - Phone:407-635-1979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health