Provider Demographics
NPI:1790317782
Name:MODLIN, PRESTON DYER (EDD)
Entity Type:Individual
Prefix:DR
First Name:PRESTON
Middle Name:DYER
Last Name:MODLIN
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 CHURCH STREET
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901
Mailing Address - Country:US
Mailing Address - Phone:304-647-6470
Mailing Address - Fax:304-647-6490
Practice Address - Street 1:635 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901
Practice Address - Country:US
Practice Address - Phone:304-647-6470
Practice Address - Fax:304-647-6490
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVL3T135100022103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool