Provider Demographics
NPI:1548756059
Name:SLADE, PRESTON ANDREW
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:ANDREW
Last Name:SLADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 E HALIFAX ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-3821
Mailing Address - Country:US
Mailing Address - Phone:480-625-2808
Mailing Address - Fax:
Practice Address - Street 1:20860 E. TATUM BLVD STE
Practice Address - Street 2:300
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050
Practice Address - Country:US
Practice Address - Phone:866-342-8847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-18-59786251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health