Healthcare Provider Details

I. General information

NPI: 1063843332
Provider Name (Legal Business Name): TIFFANY HAIRSTON PH.D, LPCC, LICDC-CS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 CHERRY ST
TOLEDO OH
43608-2906
US

IV. Provider business mailing address

1212 CHERRY ST
TOLEDO OH
43608-2906
US

V. Phone/Fax

Practice location:
  • Phone: 419-724-3133
  • Fax: 419-936-7606
Mailing address:
  • Phone: 419-724-3133
  • Fax: 419-936-7606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberO81156-CS
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE1100077
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: