Provider Demographics
NPI:1306458245
Name:HAINESWORTH, MARIO DWAYNE
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:DWAYNE
Last Name:HAINESWORTH
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 1:754 WILDWOOD DR NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-4458
Mailing Address - Country:US
Mailing Address - Phone:330-719-0660
Mailing Address - Fax:
Practice Address - Street 1:1705 WOODLAND ST NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-5348
Practice Address - Country:US
Practice Address - Phone:330-719-0660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health