Provider Demographics
NPI:1063736486
Name:HAYNES, JOSHUA D
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:D
Last Name:HAYNES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2821
Mailing Address - Country:US
Mailing Address - Phone:662-843-5347
Mailing Address - Fax:662-843-0751
Practice Address - Street 1:200 N MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2821
Practice Address - Country:US
Practice Address - Phone:662-843-5347
Practice Address - Fax:662-843-0751
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3314225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist