Provider Demographics
NPI:1033709555
Name:PRESTON, KELLY ELIZABETH (ACSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:PRESTON
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 20TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2906
Mailing Address - Country:US
Mailing Address - Phone:323-309-6001
Mailing Address - Fax:310-449-9170
Practice Address - Street 1:204 HAMPTON DR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-8633
Practice Address - Country:US
Practice Address - Phone:323-864-3726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
CA111100101YM0800X
CA912681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator