Healthcare Provider Details

I. General information

NPI: 1912755125
Provider Name (Legal Business Name): EVAN RHYS HAINES PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2024
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28955 PACIFIC COAST HWY # 200
MALIBU CA
90265-3953
US

IV. Provider business mailing address

30765 PACIFIC COAST HWY # 135
MALIBU CA
90265-3646
US

V. Phone/Fax

Practice location:
  • Phone: 888-466-9042
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number36888
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number36888
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number36888
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: