Provider Demographics
NPI:1114595634
Name:PRESTON, MONIQUE REGINA (LCSW)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:REGINA
Last Name:PRESTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1681 BAYFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20194-1513
Mailing Address - Country:US
Mailing Address - Phone:703-387-6979
Mailing Address - Fax:
Practice Address - Street 1:1681 BAYFIELD WAY
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20194-1513
Practice Address - Country:US
Practice Address - Phone:703-387-6979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040130011041C0700X
VA09030023981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0904013001OtherCLINICAL SOCIAL WORK LICENSE