Provider Demographics
NPI:1336658756
Name:PRESTON, MICHAEL (LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:PRESTON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 DECELLE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-3103
Mailing Address - Country:US
Mailing Address - Phone:321-480-5000
Mailing Address - Fax:
Practice Address - Street 1:940 EBENEZER BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6002
Practice Address - Country:US
Practice Address - Phone:321-480-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001182106H00000X
MS2198101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist