Provider Demographics
NPI:1407503253
Name:DEVINE, DESTINY DAWN (MSW)
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:DAWN
Last Name:DEVINE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:DESTINY
Other - Middle Name:DAWN
Other - Last Name:SCHOONOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:2424 BELT BUCKLE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-9537
Mailing Address - Country:US
Mailing Address - Phone:406-750-1150
Mailing Address - Fax:
Practice Address - Street 1:600 CENTRAL AVE STE 201
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-3141
Practice Address - Country:US
Practice Address - Phone:406-952-3772
Practice Address - Fax:406-952-3772
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-SWLC-LIC-552331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTBBH-SWLC-LIC-55233Medicaid