MEDICARE: MRS. ANGELA G HAIRSTON M.S., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	2202004784	VA

General Provider Information

NPI Number	:	1194988576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANGELA G HAIRSTON M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	2501 BASIN VIEW LN
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22191-6376
Country	:	US
Telephone Number	:	703-781-2457
Fax Number	:	703-799-0189

Provider Business Practice Location Address
First Line	:	9160 BELVOIR WOODS PKWY
Second Line	:
City	:	FT BELVOIR
State	:	VA
Zip	:	22060-2703
Country	:	US
Telephone Number	:	703-781-2457
Fax Number	:	703-799-0189

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2008
Last Update Date	:	07/07/2008

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