Provider Demographics
NPI:1558501585
Name:PRESTON, ANDREW STARK (PHD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:STARK
Last Name:PRESTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MAUDE ST
Mailing Address - Street 2:ELMHURST, 5TH FLOOR
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4325
Mailing Address - Country:US
Mailing Address - Phone:401-456-6587
Mailing Address - Fax:401-456-2399
Practice Address - Street 1:50 MAUDE ST
Practice Address - Street 2:ELMHURST, 5TH FLOOR
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4325
Practice Address - Country:US
Practice Address - Phone:401-456-6587
Practice Address - Fax:401-456-2399
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01094103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist