Provider Demographics
NPI:1922837996
Name:HAYNES, ANGELA SHATICE (LAC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:SHATICE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 N HARTFORD ST UNIT 1181
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-7308
Mailing Address - Country:US
Mailing Address - Phone:510-302-8917
Mailing Address - Fax:
Practice Address - Street 1:825 W WARNER RD # 1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-2926
Practice Address - Country:US
Practice Address - Phone:480-648-8183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-08184T101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health