Provider Demographics
NPI:1609902717
Name:PRESTON, BRENDA KAY (IND PROVIDER)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:PRESTON
Suffix:
Gender:F
Credentials:IND PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 E BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-2228
Mailing Address - Country:US
Mailing Address - Phone:740-362-3957
Mailing Address - Fax:
Practice Address - Street 1:222 CURTIS ST
Practice Address - Street 2:APT. 700
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-2497
Practice Address - Country:US
Practice Address - Phone:740-972-5478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2554418Medicaid