Provider Demographics
NPI:1639991144
Name:THREADGILL, HAYDEN BRYCE
Entity type:Individual
Prefix:
First Name:HAYDEN
Middle Name:BRYCE
Last Name:THREADGILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 ROMER BLVD
Mailing Address - Street 2:
Mailing Address - City:POLLOCK PINES
Mailing Address - State:CA
Mailing Address - Zip Code:95726-9242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2804 ROMER BLVD
Practice Address - Street 2:
Practice Address - City:POLLOCK PINES
Practice Address - State:CA
Practice Address - Zip Code:95726-9242
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-26
Last Update Date:2024-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician