Provider Demographics
NPI:1104159532
Name:HAYNES, ROXANNE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:ROXANNE
Middle Name:
Last Name:HAYNES
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49061 SOUTH INTERSTATE 94
Mailing Address - Street 2:APT 106
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111
Mailing Address - Country:US
Mailing Address - Phone:470-255-7723
Mailing Address - Fax:
Practice Address - Street 1:6549 TOWN CENTER DR
Practice Address - Street 2:SUITE A
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-4824
Practice Address - Country:US
Practice Address - Phone:248-620-6400
Practice Address - Fax:248-620-6405
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-17
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010884531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1041C0700XMedicaid