Provider Demographics
NPI:1720325145
Name:HAYNES, GEORGE OMAR
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:OMAR
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 1:2949 SW 126TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-2041
Mailing Address - Country:US
Mailing Address - Phone:405-921-5985
Mailing Address - Fax:
Practice Address - Street 1:8901 S SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-8413
Practice Address - Country:US
Practice Address - Phone:405-605-5757
Practice Address - Fax:405-605-5775
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst