Provider Demographics
NPI:1427418573
Name:NORMAN, DESTINY (BA)
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:NORMAN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:DESTINY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:904 M L KING DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3058
Mailing Address - Country:US
Mailing Address - Phone:618-553-1391
Mailing Address - Fax:
Practice Address - Street 1:904 M L KING DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3058
Practice Address - Country:US
Practice Address - Phone:618-553-1391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)