Provider Demographics
NPI:1619598760
Name:HERDT, PRESTON LEE (LMFT)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:LEE
Last Name:HERDT
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12396 WORLD TRADE DR STE 109
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-3787
Mailing Address - Country:US
Mailing Address - Phone:619-630-8033
Mailing Address - Fax:
Practice Address - Street 1:12396 WORLD TRADE DR STE 109
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3787
Practice Address - Country:US
Practice Address - Phone:619-630-8033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10491101YP2500X
CA128647106H00000X
390200000X
CA143009106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA128647OtherAMFT
CA10491OtherAPCC
CA143009OtherLMFT