Provider Demographics
NPI:1750864500
Name:HAYNESWORTH, NIKKI (LPC)
Entity Type:Individual
Prefix:MS
First Name:NIKKI
Middle Name:
Last Name:HAYNESWORTH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12621 N TATUM BLVD
Mailing Address - Street 2:#1629
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032
Mailing Address - Country:US
Mailing Address - Phone:585-353-6868
Mailing Address - Fax:602-266-9025
Practice Address - Street 1:12621 N TATUM BLVD
Practice Address - Street 2:#1629
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032
Practice Address - Country:US
Practice Address - Phone:480-269-2202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007895101YM0800X
AZLPC-21169101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health