Provider Demographics
NPI:1699364075
Name:HAIRSTON, NAOMI
Entity Type:Individual
Prefix:MS
First Name:NAOMI
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 1:5210 RADIUS WAY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-9099
Mailing Address - Country:US
Mailing Address - Phone:540-760-1836
Mailing Address - Fax:
Practice Address - Street 1:780 LYNNHAVEN PKWY STE 370
Practice Address - Street 2:
Practice Address - City:VA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7353
Practice Address - Country:US
Practice Address - Phone:757-301-9065
Practice Address - Fax:757-301-9067
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-19-104202106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician