MEDICARE: DR. TINA WADE-HAIRSTON PHD

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1518473685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TINA WADE-HAIRSTON PHD

Provider Business Mailing Address
First Line	:	8072 NEW ALBANY CONDIT RD
Second Line	:
City	:	WESTERVILLE
State	:	OH
Zip	:	43081-9535
Country	:	US
Telephone Number	:	614-557-1145
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 TILLER LN STE 100
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43231-2267
Country	:	US
Telephone Number	:	614-557-1145
Fax Number	:	614-557-1145

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

Provider Enumeration Date	:	12/27/2017
Last Update Date	:	04/30/2018

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