Provider Demographics
NPI:1184865016
Name:PRESTON, SHASTA NICOLE (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHASTA
Middle Name:NICOLE
Last Name:PRESTON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 NELSON PL
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-2437
Mailing Address - Country:US
Mailing Address - Phone:740-499-4070
Mailing Address - Fax:
Practice Address - Street 1:3818 STATE ROUTE 41 NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160-9184
Practice Address - Country:US
Practice Address - Phone:740-333-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP9095235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist