Basic Information
| Provider Information | |||||||||
| NPI: | 1356336903 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRESTERA CENTER FOR MENTAL HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3389 WINFIELD RD | ||||||||
| Address2: | P.O. BOX 299 | ||||||||
| City: | WINFIELD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045257851 | ||||||||
| FaxNumber: | 3045860671 | ||||||||
| Practice Location | |||||||||
| Address1: | 3375 US RT 60 E | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257050069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045257851 | ||||||||
| FaxNumber: | 3045860671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 06/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLAIR | ||||||||
| AuthorizedOfficialFirstName: | POLINA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3045257851 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MS, CPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 288 | WV | N | Agencies | Community/Behavioral Health | 273R00000X | 289 | WV | N | Hospital Units | Psychiatric Unit | 251S00000X | WV | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0991575 | 05 | OH | MEDICAID | 3810022070 | 01 | WV | BHHF | OTHER | 0005355002 | 05 | WV | MEDICAID | 001703803 | 01 | WV | BCBS CRU 273R0000X | OTHER | BP00944410 | 01 | WV | LICENSE | OTHER | 001703804 | 01 | WV | BCBS OUTPATIENT | OTHER |