Provider Demographics
NPI:1669734539
Name:HAYNES, SALLY IRONSIDE (LMHC, MAC, EMDR CERT)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:IRONSIDE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:LMHC, MAC, EMDR CERT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5685
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-5685
Mailing Address - Country:US
Mailing Address - Phone:704-762-7400
Mailing Address - Fax:
Practice Address - Street 1:611 SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3437
Practice Address - Country:US
Practice Address - Phone:704-762-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29553101YA0400X
NC19409101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)