Basic Information
| Provider Information | |||||||||
| NPI: | 1457901035 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAINES | ||||||||
| FirstName: | PENDRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2077 | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954822077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074672010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 99 S HUMBOLDT ST | ||||||||
| Address2: | |||||||||
| City: | WILLITS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954903509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074599900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2019 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 91188 | CA | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 91188 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 99188 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.