Provider Demographics
NPI:1255718078
Name:HAIRSTON, BRIAN MAURICE
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:MAURICE
Last Name:HAIRSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 SHERIDAN ST APT C8
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08104-1737
Mailing Address - Country:US
Mailing Address - Phone:856-655-9354
Mailing Address - Fax:
Practice Address - Street 1:1440 SHERIDAN ST APT C8
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08104-1737
Practice Address - Country:US
Practice Address - Phone:856-655-9354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJH01970967404922101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health