Healthcare Provider Details

I. General information

NPI: 1376000646
Provider Name (Legal Business Name): SYDNEY HAYNES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 11/18/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 FIREWAY LANE
WILLOW CREEK CA
95573-0724
US

IV. Provider business mailing address

PO BOX 724
WILLOW CREEK CA
95573-0724
US

V. Phone/Fax

Practice location:
  • Phone: 541-292-6021
  • Fax:
Mailing address:
  • Phone: 541-292-6021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW104076
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: