Provider Demographics
NPI:1962111518
Name:HAIRSTON, SHAWNDREDI ISLA-MARIE
Entity type:Individual
Prefix:MS
First Name:SHAWNDREDI
Middle Name:ISLA-MARIE
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 1:3618 MOSBY DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-4433
Mailing Address - Country:US
Mailing Address - Phone:336-523-7851
Mailing Address - Fax:
Practice Address - Street 1:3618 MOSBY DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-4433
Practice Address - Country:US
Practice Address - Phone:336-523-7851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician