Basic Information
| Provider Information | |||||||||
| NPI: | 1306498134 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRESTON | ||||||||
| FirstName: | ETHAN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 108 | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456380108 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456381502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405321613 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2019 | ||||||||
| LastUpdateDate: | 07/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.170962 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | CDCA.170962 | OH | N | Other Service Providers | Case Manager/Care Coordinator | 171M00000X | CDCA.175127 | OH | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 0358491 | 05 | OH | MEDICAID |