Basic Information
| Provider Information | |||||||||
| NPI: | 1639735442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAINES | ||||||||
| FirstName: | HAYDEN | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 NE 3RD ST # B4-332 | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977542925 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1103 NE ELM ST | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977541664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413235330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2019 | ||||||||
| LastUpdateDate: | 05/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3210 | AL | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | C5302 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.