=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407574189
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOI HAYNES LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2022
-----------------------------------------------------
Last Update Date | 12/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4053 183RD ST UNIT 2007
-----------------------------------------------------
City | COUNTRY CLUB HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60478-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-440-2458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4814 SUNSET LN
-----------------------------------------------------
City | COUNTRY CLUB HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60478-4574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-440-2458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149027980
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------