Provider Demographics
NPI:1598932105
Name:PRESTON, LYA
Entity Type:Individual
Prefix:
First Name:LYA
Middle Name:
Last Name:PRESTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYA
Other - Middle Name:
Other - Last Name:GAUTHIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:516 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:EAST TAWAS
Mailing Address - State:MI
Mailing Address - Zip Code:48730-1534
Mailing Address - Country:US
Mailing Address - Phone:989-362-0269
Mailing Address - Fax:
Practice Address - Street 1:301 LONG RAPIDS RD
Practice Address - Street 2:TENDERCARE ALPENA
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707
Practice Address - Country:US
Practice Address - Phone:989-356-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202006819224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant