Provider Demographics
NPI:1992514467
Name:HAYNES, MARY (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HAYNES
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20470 N LAKE PLEASANT RD STE 107
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9708
Mailing Address - Country:US
Mailing Address - Phone:623-322-8250
Mailing Address - Fax:
Practice Address - Street 1:20470 N LAKE PLEASANT RD STE 107
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-9708
Practice Address - Country:US
Practice Address - Phone:623-322-8250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1775225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist