Provider Demographics
NPI:1972190346
Name:HAYNIE, CHASE GASTON (PTA)
Entity Type:Individual
Prefix:
First Name:CHASE
Middle Name:GASTON
Last Name:HAYNIE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 RIDGECREST DR
Mailing Address - Street 2:
Mailing Address - City:POPE
Mailing Address - State:MS
Mailing Address - Zip Code:38658-3150
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1120 RITCHIE AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-7535
Practice Address - Country:US
Practice Address - Phone:662-621-1447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA-6504225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist