Provider Demographics
NPI:1821405952
Name:HAIRSTON, LISA WAGONER (LCMHC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:WAGONER
Last Name:HAIRSTON
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 LEWISVILLE CLEMMONS RD STE E
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-7460
Mailing Address - Country:US
Mailing Address - Phone:336-766-0505
Mailing Address - Fax:336-766-0505
Practice Address - Street 1:2255 LEWISVILLE CLEMMONS RD STE E
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-7460
Practice Address - Country:US
Practice Address - Phone:336-766-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10908101YM0800X, 101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health