Provider Demographics
NPI:1700274917
Name:PRESTON, ALYSSA (PTA)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:PRESTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10951 N 91ST AVE LOT 241
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-8651
Mailing Address - Country:US
Mailing Address - Phone:623-414-6837
Mailing Address - Fax:
Practice Address - Street 1:1400 E SOUTHERN AVE STE 310
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-5695
Practice Address - Country:US
Practice Address - Phone:877-279-0891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11342A172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker