Provider Demographics
NPI:1164195483
Name:LEA, DESTINY INEZ
Entity Type:Individual
Prefix:MS
First Name:DESTINY
Middle Name:INEZ
Last Name:LEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DESTINY
Other - Middle Name:INEZ
Other - Last Name:LEA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:202 DINK ASHLEY RD
Mailing Address - Street 2:
Mailing Address - City:TIMBERLAKE
Mailing Address - State:NC
Mailing Address - Zip Code:27583-9238
Mailing Address - Country:US
Mailing Address - Phone:919-636-8204
Mailing Address - Fax:
Practice Address - Street 1:615 WHEAT MILL RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-1242
Practice Address - Country:US
Practice Address - Phone:252-452-7346
Practice Address - Fax:919-937-2046
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician