Provider Demographics
NPI:1295401412
Name:CORDELL, DESTINY
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:CORDELL
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 1:113 SNOW RD
Mailing Address - Street 2:
Mailing Address - City:WEST BROOKFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01585-2700
Mailing Address - Country:US
Mailing Address - Phone:774-334-4741
Mailing Address - Fax:
Practice Address - Street 1:42 EDWARDS ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-1937
Practice Address - Country:US
Practice Address - Phone:774-318-1806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician