Provider Demographics
NPI:1710510961
Name:LA HAISE, INDIA MAY
Entity Type:Individual
Prefix:
First Name:INDIA
Middle Name:MAY
Last Name:LA HAISE
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 1:252 RENDEZVOUS LN
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-1253
Mailing Address - Country:US
Mailing Address - Phone:904-504-0153
Mailing Address - Fax:
Practice Address - Street 1:4624 PARK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-7327
Practice Address - Country:US
Practice Address - Phone:904-503-0131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician