Provider Demographics
NPI:1366022469
Name:SHARACK, DESTINY
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:SHARACK
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 1:22 VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:HAZLET
Mailing Address - State:NJ
Mailing Address - Zip Code:07730-1532
Mailing Address - Country:US
Mailing Address - Phone:732-440-9141
Mailing Address - Fax:
Practice Address - Street 1:22 VILLAGE CT
Practice Address - Street 2:
Practice Address - City:HAZLET
Practice Address - State:NJ
Practice Address - Zip Code:07730-1532
Practice Address - Country:US
Practice Address - Phone:732-440-9141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06320100104100000X
NJ44SC060408001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker