Provider Demographics
NPI:1073278933
Name:MCCULLORS, DESTANY DELAINE (RBT)
Entity Type:Individual
Prefix:
First Name:DESTANY
Middle Name:DELAINE
Last Name:MCCULLORS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 SAINT JOHNS AVE STE 15-214
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-1852
Mailing Address - Country:US
Mailing Address - Phone:352-872-2852
Mailing Address - Fax:904-212-0929
Practice Address - Street 1:1912 HAMILTON ST STE 108
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-2077
Practice Address - Country:US
Practice Address - Phone:904-752-0642
Practice Address - Fax:904-212-0929
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-05
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-137243106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113301300Medicaid