Provider Demographics
NPI:1003564907
Name:NEWBERRY, DESTINY MARIE
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:MARIE
Last Name:NEWBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TAFT
Mailing Address - State:CA
Mailing Address - Zip Code:93268-2433
Mailing Address - Country:US
Mailing Address - Phone:661-765-7025
Mailing Address - Fax:
Practice Address - Street 1:1021 4TH ST
Practice Address - Street 2:
Practice Address - City:TAFT
Practice Address - State:CA
Practice Address - Zip Code:93268-2433
Practice Address - Country:US
Practice Address - Phone:661-765-7025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
175T00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist