MEDICARE: MS. NIKKI HAYNESWORTH LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	007895	NY
2	101YP2500X	Professional Counselor	LPC-21169	AZ

General Provider Information

NPI Number	:	1750864500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NIKKI HAYNESWORTH LPC

Provider Business Mailing Address
First Line	:	12621 N TATUM BLVD
Second Line	:	#1629
City	:	PHOENIX
State	:	AZ
Zip	:	85032
Country	:	US
Telephone Number	:	585-353-6868
Fax Number	:	602-266-9025

Provider Business Practice Location Address
First Line	:	12621 N TATUM BLVD
Second Line	:	#1629
City	:	PHOENIX
State	:	AZ
Zip	:	85032
Country	:	US
Telephone Number	:	480-269-2202
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2018
Last Update Date	:	02/01/2024

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