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General NPI Number Information
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NPI Number | 1033016779
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Entity Type | Individual
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Provider Name | KURTIS HAYNESWORTH
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Gender | Male
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Dates
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Enumeration Date | 10/26/2026
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Last Update Date | 10/26/2026
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Provider Practice Location Address
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Address Line | 124 VILLAGE PARK DR
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City | POCONO LAKE
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State | PA
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Zip | 18347-8215
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Country | US
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Telephone | 570-307-9079
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Fax |
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Provider Business Mailing Address
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Address Line | 114 W 3RD ST
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City | WIND GAP
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State | PA
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Zip | 18091-1507
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | PC021192
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License Number State | PA
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