Provider Demographics
NPI:1437276912
Name:HAIRSTON, CYNTHIA DIANNE (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:DIANNE
Last Name:HAIRSTON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:DIANNE
Other - Last Name:SURPRENANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:54 WELLESLEY LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-7867
Mailing Address - Country:US
Mailing Address - Phone:386-451-0684
Mailing Address - Fax:
Practice Address - Street 1:1 HARGROVE GRADE STE 1B
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-5116
Practice Address - Country:US
Practice Address - Phone:386-643-3115
Practice Address - Fax:386-276-3474
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12217101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH12217OtherSTATE LICENSE