Provider Demographics
NPI:1215147582
Name:PRESTIN, AMY A (LCPC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:A
Last Name:PRESTIN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 E 3719 N
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-2011
Mailing Address - Country:US
Mailing Address - Phone:208-280-1054
Mailing Address - Fax:
Practice Address - Street 1:2504 E 3719 N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-2011
Practice Address - Country:US
Practice Address - Phone:208-280-1054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC3831041C0700X
IDLCPC8067101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804052700Medicaid