Basic Information
| Provider Information | |||||||||
| NPI: | 1669905832 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HAYNES FAMILY OF PROGRAMS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | HAYNES FP STRTP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 233 WEST BASELINE RD | ||||||||
| Address2: | BOX 400 | ||||||||
| City: | LA VERNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917502353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095932581 | ||||||||
| FaxNumber: | 9096147466 | ||||||||
| Practice Location | |||||||||
| Address1: | 233 WEST BASELINE ROAD | ||||||||
| Address2: | |||||||||
| City: | LA VERNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917502353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095932581 | ||||||||
| FaxNumber: | 9098332998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2017 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | CASSANDRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | STRTP ASSISTANT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9095932581 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 0175.00.02 | 01 | CA | FACILITY LICENSE | OTHER |