Provider Demographics
NPI:1679843742
Name:PRESTON, LEVI M (CSAC)
Entity Type:Individual
Prefix:
First Name:LEVI
Middle Name:M
Last Name:PRESTON
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:MR
Other - First Name:LEVI
Other - Middle Name:M
Other - Last Name:PRESTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CSAC
Mailing Address - Street 1:2677 N 40TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-2505
Mailing Address - Country:US
Mailing Address - Phone:414-447-1965
Mailing Address - Fax:414-447-1964
Practice Address - Street 1:2677 N 40TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210
Practice Address - Country:US
Practice Address - Phone:414-447-1965
Practice Address - Fax:414-447-1964
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15853-132101YA0400X, 101YA0400X
WI16329-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100029517Medicaid