Provider Demographics
NPI:1992314207
Name:HASKINS, MICHAEL KELLY
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KELLY
Last Name:HASKINS
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 1:11485 W MASSINGALE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85743-9404
Mailing Address - Country:US
Mailing Address - Phone:520-251-8282
Mailing Address - Fax:
Practice Address - Street 1:11485 W MASSINGALE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85743-9404
Practice Address - Country:US
Practice Address - Phone:520-251-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD08823157106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician