Basic Information
| Provider Information | |||||||||
| NPI: | 1124676895 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRESTON | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | LCSW-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 132 HOLIDAY COURT | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102244207 | ||||||||
| FaxNumber: | 4102245659 | ||||||||
| Practice Location | |||||||||
| Address1: | 132 HOLIDAY COURT | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102244207 | ||||||||
| FaxNumber: | 4102245659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2019 | ||||||||
| LastUpdateDate: | 08/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 09073 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.