Basic Information
| Provider Information | |||||||||
| NPI: | 1417310608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAYNES | ||||||||
| FirstName: | CODY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 SUWANNEE TAIL ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421037956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709015000 | ||||||||
| FaxNumber: | 2708425268 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 SUWANNEE TAIL ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421037956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709015000 | ||||||||
| FaxNumber: | 2708425268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2016 | ||||||||
| LastUpdateDate: | 12/21/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 172913 | KY | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.