Provider Demographics
NPI:1699443242
Name:HAIRSTON, MARIAH L
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:L
Last Name:HAIRSTON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:L
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1640 SUNNY BROOK LN NE APT A212
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-6513
Mailing Address - Country:US
Mailing Address - Phone:407-431-7224
Mailing Address - Fax:
Practice Address - Street 1:3880 CATALINA ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2211
Practice Address - Country:US
Practice Address - Phone:321-346-8450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-156605106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111771100Medicaid