Provider Demographics
NPI:1326465360
Name:WHOLLEY, PRESTON TYLER (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PRESTON
Middle Name:TYLER
Last Name:WHOLLEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 W 133RD ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-3301
Mailing Address - Country:US
Mailing Address - Phone:646-762-4950
Mailing Address - Fax:646-762-4951
Practice Address - Street 1:169 W 133RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030
Practice Address - Country:US
Practice Address - Phone:646-762-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
NY0895571041C0700X
NY0850201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1326465360Medicaid