Provider Demographics
NPI:1265880835
Name:HAYNES, SHANTELL (MFT)
Entity type:Individual
Prefix:
First Name:SHANTELL
Middle Name:
Last Name:HAYNES
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3585 NE 207TH ST
Mailing Address - Street 2:C-9 #741
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-3772
Mailing Address - Country:US
Mailing Address - Phone:407-402-0129
Mailing Address - Fax:
Practice Address - Street 1:3585 NE 207TH ST
Practice Address - Street 2:C-9 #741
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-3772
Practice Address - Country:US
Practice Address - Phone:407-402-0129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT2197106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist