Provider Demographics
NPI:1366831273
Name:PETERSON, DESTINY
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERAPY WITH
Other - Middle Name:
Other - Last Name:DESTINY, LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:21415 CIVIC CENTER DR STE 209
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3943
Mailing Address - Country:US
Mailing Address - Phone:248-703-2889
Mailing Address - Fax:
Practice Address - Street 1:21415 CIVIC CENTER DR STE 209
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3943
Practice Address - Country:US
Practice Address - Phone:248-703-2889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000917174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7501000917OtherSTATE OF MICHIGAN LICENSING BOARD NUMBER