Provider Demographics
NPI:1821644311
Name:HAYNES, MARILYN
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:HAYNES
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 1:519 N SAM HOUSTON PKWY E
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-4051
Mailing Address - Country:US
Mailing Address - Phone:832-943-4035
Mailing Address - Fax:
Practice Address - Street 1:519 N SAM HOUSTON PKWY E
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-4051
Practice Address - Country:US
Practice Address - Phone:832-943-4035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX373188702Medicaid