Provider Demographics
NPI:1932742335
Name:HAIRSTON, KENBERLY
Entity Type:Individual
Prefix:MRS
First Name:KENBERLY
Middle Name:
Last Name:HAIRSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KENBERLY
Other - Middle Name:
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6635 FLORENCE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BELL GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90201-4968
Mailing Address - Country:US
Mailing Address - Phone:323-647-6740
Mailing Address - Fax:
Practice Address - Street 1:6635 FLORENCE AVE STE 101
Practice Address - Street 2:
Practice Address - City:BELL GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90201-4968
Practice Address - Country:US
Practice Address - Phone:323-647-6740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95499101YM0800X
225400000X, 390200000X
CA1170161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program