Provider Demographics
NPI:1679789432
Name:HAYNES, MICHELLE TANYA (MS CCC SLP)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:TANYA
Last Name:HAYNES
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6734 31ST WAY SOUTH
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-5406
Mailing Address - Country:US
Mailing Address - Phone:727-776-5534
Mailing Address - Fax:727-546-8527
Practice Address - Street 1:6734 31ST WAY SOUTH
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-5406
Practice Address - Country:US
Practice Address - Phone:727-776-5534
Practice Address - Fax:727-546-8527
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8088235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891090100Medicaid