Provider Demographics
NPI:1790573558
Name:HAYNES, NATHANAEL
Entity type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:
Last Name:HAYNES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 MIDDLESEX AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155
Mailing Address - Country:US
Mailing Address - Phone:617-596-5730
Mailing Address - Fax:
Practice Address - Street 1:11 MIDDLESEX AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:MA
Practice Address - Zip Code:01887-2771
Practice Address - Country:US
Practice Address - Phone:617-596-5730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health