Provider Demographics
NPI:1801095625
Name:HAYNES, DOROTHY (MA,CCS,NCAC2,SAP,RAS)
Entity type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:
Last Name:HAYNES
Suffix:
Gender:F
Credentials:MA,CCS,NCAC2,SAP,RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 EL PORTAL DR
Mailing Address - Street 2:SUITE #206
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3305
Mailing Address - Country:US
Mailing Address - Phone:510-374-7011
Mailing Address - Fax:
Practice Address - Street 1:2523 EL PORTAL DR
Practice Address - Street 2:SUITE #206
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3305
Practice Address - Country:US
Practice Address - Phone:510-374-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAH0501041743171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator