MEDICARE: ANGELA SHATICE HAYNES LAC

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	LAC-08184T	AZ

General Provider Information

NPI Number	:	1922837996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA SHATICE HAYNES LAC

Provider Business Mailing Address
First Line	:	1961 N HARTFORD ST UNIT 1181
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85225-7308
Country	:	US
Telephone Number	:	510-302-8917
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 W WARNER RD # 1
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85225-2926
Country	:	US
Telephone Number	:	480-648-8183
Fax Number	:

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

Provider Enumeration Date	:	07/29/2024
Last Update Date	:	07/29/2024

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