Healthcare Provider Details

I. General information

NPI: 1467548123
Provider Name (Legal Business Name): SHELLI LYNN HAYNES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 SW PARKWAY DR
REDMOND OR
97756-2581
US

IV. Provider business mailing address

63417 LEDGESTONE CT
BEND OR
97701-7723
US

V. Phone/Fax

Practice location:
  • Phone: 585-624-1350
  • Fax:
Mailing address:
  • Phone: 585-233-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR052334
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL4279
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: