Provider Demographics
NPI:1902992324
Name:HAYNES, JUDITH ANN (PHD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:HAYNES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:ANN
Other - Last Name:KAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1407 24TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1407 24TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6761
Practice Address - Country:US
Practice Address - Phone:701-746-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND176103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND085222OtherVALUE OPTIONS
ND12892Medicaid
ND24741OtherBLUECROSSBLUESHIELD OF ND
MN638K4HAOtherBLUECROSSBLUESHIELD OF MN
ND085222OtherVALUE OPTIONS