Provider Demographics
NPI:1053024562
Name:HAYNES, ELIZABETH M
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:HAYNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 BOYS REPUBLIC DR
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5447
Mailing Address - Country:US
Mailing Address - Phone:909-628-1217
Mailing Address - Fax:909-306-5427
Practice Address - Street 1:14505 KRAMER RANCH RD
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5454
Practice Address - Country:US
Practice Address - Phone:909-740-3137
Practice Address - Fax:909-306-5427
Is Sole Proprietor?:No
Enumeration Date:2022-12-29
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12514101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health