Provider Demographics
NPI:1912473208
Name:HAYNES, WENDY LEE (PT)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:LEE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3741 SKYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1660
Mailing Address - Country:US
Mailing Address - Phone:707-528-4080
Mailing Address - Fax:
Practice Address - Street 1:7840 OLD REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:COTATI
Practice Address - State:CA
Practice Address - Zip Code:94931-5106
Practice Address - Country:US
Practice Address - Phone:707-795-1636
Practice Address - Fax:707-795-2273
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9501225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty