Healthcare Provider Details

I. General information

NPI: 1861439572
Provider Name (Legal Business Name): ELESE L HAIRSTON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UPC LIVONIA 16836 NEWBURGH RD
LIVONIA MI
48154
US

IV. Provider business mailing address

1560 E MAPLE RD SUITE 400 - CREDENTIALING
TROY MI
48083-1138
US

V. Phone/Fax

Practice location:
  • Phone: 888-362-7792
  • Fax:
Mailing address:
  • Phone: 248-581-5971
  • Fax: 248-581-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801004853
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: