Provider Demographics
NPI:1073017182
Name:DESTIN, MATHEWS
Entity Type:Individual
Prefix:
First Name:MATHEWS
Middle Name:
Last Name:DESTIN
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 1:1722 SW COMFORT ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2026
Mailing Address - Country:US
Mailing Address - Phone:772-206-5116
Mailing Address - Fax:
Practice Address - Street 1:1722 SW COMFORT ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2026
Practice Address - Country:US
Practice Address - Phone:772-206-5116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician