=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093479420
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEIDRE HAYES LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2021
-----------------------------------------------------
Last Update Date | 10/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 N KENDRICK ST
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-1582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-850-0192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6401 N CHRISTMAS TREE LN APT 4
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86004-2650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-850-0192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC-20376
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------