Provider Demographics
NPI:1548496524
Name:HAYNES, GEORGIA LEROY (MSW)
Entity type:Individual
Prefix:MS
First Name:GEORGIA
Middle Name:LEROY
Last Name:HAYNES
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2627
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:3031 HOT SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4288
Practice Address - Country:US
Practice Address - Phone:505-425-9464
Practice Address - Fax:505-425-8420
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX06369104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM85024558Medicare Oscar/Certification