Healthcare Provider Details

I. General information

NPI: 1790366540
Provider Name (Legal Business Name): MARTHA HAYNES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12425 KNOLL RD STE 110
ELM GROVE WI
53122-2656
US

IV. Provider business mailing address

822 HEATHER DR
ELKHORN WI
53121-1193
US

V. Phone/Fax

Practice location:
  • Phone: 262-292-9991
  • Fax:
Mailing address:
  • Phone: 262-723-1345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2002-124
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: