Healthcare Provider Details

I. General information

NPI: 1881474997
Provider Name (Legal Business Name): TOSHA L HAIRSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2023
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6440 DOBBIN RD STE D
COLUMBIA MD
21045-4770
US

IV. Provider business mailing address

5031 BRADLEY BLVD APT 4
CHEVY CHASE MD
20815-6575
US

V. Phone/Fax

Practice location:
  • Phone: 410-730-2385
  • Fax:
Mailing address:
  • Phone: 857-919-0722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP14386
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: