Provider Demographics
NPI:1346650298
Name:HAYNES, JUDSON AUSTIN
Entity type:Individual
Prefix:MR
First Name:JUDSON
Middle Name:AUSTIN
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 1:3888 NW RANDALL WAY STE 201
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7847
Mailing Address - Country:US
Mailing Address - Phone:360-698-5883
Mailing Address - Fax:360-809-6002
Practice Address - Street 1:260 KALA POINT DR STE 102
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-9530
Practice Address - Country:US
Practice Address - Phone:360-698-5883
Practice Address - Fax:360-809-6002
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60211997101YA0400X
WALH60531241101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2254794Medicaid