Provider Demographics
NPI:1275043283
Name:HAIRSTON, MARTINA (MA)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:HAIRSTON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6923 WILLIAM RD
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-6205
Mailing Address - Country:US
Mailing Address - Phone:470-767-7437
Mailing Address - Fax:
Practice Address - Street 1:2636 MLK JR DR SW STE 22
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-1635
Practice Address - Country:US
Practice Address - Phone:678-705-3828
Practice Address - Fax:678-705-3828
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor