Provider Demographics
NPI:1114273471
Name:BANKHEAD, DESTINY MARIE (MS, LPSC)
Entity Type:Individual
Prefix:MS
First Name:DESTINY
Middle Name:MARIE
Last Name:BANKHEAD
Suffix:
Gender:F
Credentials:MS, LPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 SE OAK GROVE BLVD APT 27
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-1474
Mailing Address - Country:US
Mailing Address - Phone:503-935-3226
Mailing Address - Fax:
Practice Address - Street 1:10011 SE DIVISION ST
Practice Address - Street 2:SUITE # 305
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1351
Practice Address - Country:US
Practice Address - Phone:503-335-5975
Practice Address - Fax:503-335-5974
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health