Provider Demographics
NPI:1366885196
Name:PRESTON, CAROLYN JOANNE (LMT, MMT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JOANNE
Last Name:PRESTON
Suffix:
Gender:F
Credentials:LMT, MMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-2844
Mailing Address - Country:US
Mailing Address - Phone:352-587-5964
Mailing Address - Fax:
Practice Address - Street 1:1013 BROOKSIDE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:WESCOSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18106
Practice Address - Country:US
Practice Address - Phone:267-901-4093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG008600225700000X
NH3742M225700000X
FLMA84921225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist