Basic Information
Provider Information | |||||||||
NPI: | 1972976421 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PRESTEGORD | ||||||||
FirstName: | ADAM | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2205 BELLE VIEW BLVD | ||||||||
Address2: |   | ||||||||
City: | ALEXANDRIA | ||||||||
State: | VA | ||||||||
PostalCode: | 223071327 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6128017442 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6677 RICHMOND HWY | ||||||||
Address2: |   | ||||||||
City: | ALEXANDRIA | ||||||||
State: | VA | ||||||||
PostalCode: | 223066647 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7035355568 | ||||||||
FaxNumber: | 7035351583 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/05/2015 | ||||||||
LastUpdateDate: | 11/05/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0711000152 | VA | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 0904009181 | VA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.