Provider Demographics
NPI:1134337736
Name:HAYNES, LAINE (LCSW)
Entity type:Individual
Prefix:MS
First Name:LAINE
Middle Name:
Last Name:HAYNES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:LAINE
Other - Middle Name:
Other - Last Name:VILENSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3554 ROUND BARN BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-0929
Mailing Address - Country:US
Mailing Address - Phone:707-571-3884
Mailing Address - Fax:
Practice Address - Street 1:3554 ROUND BARN BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-0929
Practice Address - Country:US
Practice Address - Phone:707-571-3884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALK131981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMMM00289MMedicare ID - Type Unspecified