Provider Demographics
NPI:1093900318
Name:PRESTON, ERICA (PSYD)
Entity Type:Individual
Prefix:MS
First Name:ERICA
Middle Name:
Last Name:PRESTON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SHAWS CV
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4902
Mailing Address - Country:US
Mailing Address - Phone:860-447-8304
Mailing Address - Fax:860-443-8720
Practice Address - Street 1:1 SHAWS CV
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4902
Practice Address - Country:US
Practice Address - Phone:860-447-8304
Practice Address - Fax:860-443-8720
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CT003273103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236338Medicaid