Provider Demographics
NPI:1871045187
Name:HAIRE, CARYN
Entity Type:Individual
Prefix:
First Name:CARYN
Middle Name:
Last Name:HAIRE
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 1:853 BATTLECREEK RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-1919
Mailing Address - Country:US
Mailing Address - Phone:770-603-4686
Mailing Address - Fax:770-478-8722
Practice Address - Street 1:853 BATTLECREEK RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1919
Practice Address - Country:US
Practice Address - Phone:770-603-4686
Practice Address - Fax:770-478-8722
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC004277101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1518932078Medicaid