Provider Demographics
NPI:1770043010
Name:HAILEY, HAVYNN NICOLE
Entity Type:Individual
Prefix:
First Name:HAVYNN
Middle Name:NICOLE
Last Name:HAILEY
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 1:3428 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-3339
Mailing Address - Country:US
Mailing Address - Phone:330-668-4041
Mailing Address - Fax:
Practice Address - Street 1:3428 W MARKET ST
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3339
Practice Address - Country:US
Practice Address - Phone:330-688-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty