Provider Demographics
NPI:1427776723
Name:HAYNES, PENNY SUE (CADC II)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:SUE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30142-0006
Mailing Address - Country:US
Mailing Address - Phone:678-459-2437
Mailing Address - Fax:888-826-6972
Practice Address - Street 1:347 HOLLY ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-9568
Practice Address - Country:US
Practice Address - Phone:678-459-2437
Practice Address - Fax:888-826-6972
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1348101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)