Provider Demographics
NPI:1972976421
Name:PRESTEGORD, ADAM C
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:C
Last Name:PRESTEGORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 BELLE VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22307-1327
Mailing Address - Country:US
Mailing Address - Phone:612-801-7442
Mailing Address - Fax:
Practice Address - Street 1:6677 RICHMOND HWY
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-6647
Practice Address - Country:US
Practice Address - Phone:703-535-5568
Practice Address - Fax:703-535-1583
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0711000152101YA0400X
VA09040091811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)