Provider Demographics
NPI:1568206621
Name:HAYNES, DOMINIQUE MERIA
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MERIA
Last Name:HAYNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9116 CLEO SMITH RD
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-8529
Mailing Address - Country:US
Mailing Address - Phone:228-363-5637
Mailing Address - Fax:
Practice Address - Street 1:9414 THREE RIVERS RD STE 3
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3861
Practice Address - Country:US
Practice Address - Phone:228-305-0469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health