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General NPI Number Information
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NPI Number | 1487388963
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Entity Type | Individual
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Provider Name | LARRY HAYNES
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Gender | Male
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Dates
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Enumeration Date | 07/12/2022
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Last Update Date | 07/12/2022
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Provider Practice Location Address
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Address Line | 9697 191ST ST
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City | MOKENA
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State | IL
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Zip | 60448-8609
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Country | US
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Telephone | 312-815-9660
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Fax |
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Provider Business Mailing Address
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Address Line | 18036 OLYMPIA DR
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City | COUNTRY CLUB HILLS
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State | IL
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Zip | 60478-5168
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Country | US
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Telephone | 773-655-4877
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State | IL
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