Healthcare Provider Details

I. General information

NPI: 1356995849
Provider Name (Legal Business Name): JULIANNE BRIELLE HAYNES M.C.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 E 70TH ST STE A
SHREVEPORT LA
71105-5345
US

IV. Provider business mailing address

147 E ELMWOOD ST
SHREVEPORT LA
71104-4529
US

V. Phone/Fax

Practice location:
  • Phone: 318-219-6064
  • Fax:
Mailing address:
  • Phone: 318-469-6872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number8415
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: