Healthcare Provider Details

I. General information

NPI: 1720693526
Provider Name (Legal Business Name): TYRI HAYNIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E SHAW AVE STE 149
FRESNO CA
93710-7903
US

IV. Provider business mailing address

6622 N MAROA AVE
FRESNO CA
93704-1209
US

V. Phone/Fax

Practice location:
  • Phone: 559-554-9710
  • Fax:
Mailing address:
  • Phone: 559-575-8172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: