Healthcare Provider Details

I. General information

NPI: 1548195902
Provider Name (Legal Business Name): MR. DERRICK TRAVON HAYES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 W AVENUE J STE 202
LANCASTER CA
93534-2861
US

IV. Provider business mailing address

1672 W AVENUE J STE 202
LANCASTER CA
93534-2861
US

V. Phone/Fax

Practice location:
  • Phone: 661-214-3044
  • Fax:
Mailing address:
  • Phone: 661-214-3044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number22409
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: