Healthcare Provider Details

I. General information

NPI: 1336658756
Provider Name (Legal Business Name): MICHAEL PRESTON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 09/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 EBENEZER BLVD
MADISON MS
39110-6002
US

IV. Provider business mailing address

416 DECELLE ST
JACKSON MS
39216-3103
US

V. Phone/Fax

Practice location:
  • Phone: 321-480-5000
  • Fax:
Mailing address:
  • Phone: 321-480-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2198
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001182
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: