Healthcare Provider Details

I. General information

NPI: 1487388963
Provider Name (Legal Business Name): LARRY HAYNES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9697 191ST ST
MOKENA IL
60448-8609
US

IV. Provider business mailing address

18036 OLYMPIA DR
COUNTRY CLUB HILLS IL
60478-5168
US

V. Phone/Fax

Practice location:
  • Phone: 312-815-9660
  • Fax:
Mailing address:
  • Phone: 773-655-4877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: