Provider Demographics
NPI:1851642193
Name:HAYNES FAMILY OF PROGRAMS
Entity Type:Organization
Organization Name:HAYNES FAMILY OF PROGRAMS
Other - Org Name:LEROY HAYNES CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAYDECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-593-2581
Mailing Address - Street 1:1025 SENTINEL DR
Mailing Address - Street 2:SUITES 200 & 206
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3280
Mailing Address - Country:US
Mailing Address - Phone:909-833-2986
Mailing Address - Fax:
Practice Address - Street 1:1025 SENTINEL DR
Practice Address - Street 2:SUITES 200 & 206
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3280
Practice Address - Country:US
Practice Address - Phone:909-833-2986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-26
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000697251S00000X, 252Y00000X, 261QM0801X, 261QM0855X
CA191501972320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health