Provider Demographics
NPI:1336883982
Name:PRESTON, DESTINY MARIE
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:MARIE
Last Name:PRESTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-4934
Mailing Address - Country:US
Mailing Address - Phone:310-923-2843
Mailing Address - Fax:
Practice Address - Street 1:427 F ST STE 205
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1040
Practice Address - Country:US
Practice Address - Phone:707-633-8179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88875225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist