Provider Demographics
NPI:1477237188
Name:WALLS, DESTINY MARIE
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:MARIE
Last Name:WALLS
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 1:188 W ILLINOIS HWY
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-5501
Mailing Address - Country:US
Mailing Address - Phone:779-803-1373
Mailing Address - Fax:
Practice Address - Street 1:188 W ILLINOIS HWY
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-5501
Practice Address - Country:US
Practice Address - Phone:779-803-1373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician