Provider Demographics
NPI:1871987560
Name:HAYES, CHANNELL MARIE
Entity type:Individual
Prefix:
First Name:CHANNELL
Middle Name:MARIE
Last Name:HAYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 K ST NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1801
Mailing Address - Country:US
Mailing Address - Phone:580-504-7718
Mailing Address - Fax:
Practice Address - Street 1:1219 K ST NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1801
Practice Address - Country:US
Practice Address - Phone:580-798-4523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit