Provider Demographics
NPI:1871673269
Name:PRESTON, MICHAEL J (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:PRESTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 LIBBEY INDUSTRIAL PKWY
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02189-3101
Mailing Address - Country:US
Mailing Address - Phone:781-682-1060
Mailing Address - Fax:781-682-1061
Practice Address - Street 1:169 LIBBEY INDUSTRIAL PKWY
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02189-3101
Practice Address - Country:US
Practice Address - Phone:781-682-1060
Practice Address - Fax:781-682-1061
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4195103G00000X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD461315000OtherMAGELLAN PROVIDER NUMBER
MD1047128OtherCIGNA PROVIDER NUMBER
MD6101022OtherEVERCARE PROVIDER NUMBER
MA0503509Medicaid
MDW06395OtherBCBS PROVIDER NUMBER
MD461315000OtherMAGELLAN PROVIDER NUMBER