Provider Demographics
NPI:1386349322
Name:HAIRSTON, SHANTE
Entity type:Individual
Prefix:
First Name:SHANTE
Middle Name:
Last Name:HAIRSTON
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 1:640 GRASSMERE PARK STE 116
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-3678
Mailing Address - Country:US
Mailing Address - Phone:312-965-2997
Mailing Address - Fax:312-929-0324
Practice Address - Street 1:7131 AMBASSADOR RD STE 150
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-3077
Practice Address - Country:US
Practice Address - Phone:312-965-2997
Practice Address - Fax:312-929-0324
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician