Provider Demographics
NPI:1407462047
Name:GARCIA, DESTINY RAYLEEN
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:RAYLEEN
Last Name:GARCIA
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 1:14120 MCCLURE AVE
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-2224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14120 MCCLURE AVE
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-2224
Practice Address - Country:US
Practice Address - Phone:562-292-7650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA97619806D24343Medicaid