Provider Demographics
NPI:1508441007
Name:DAVALOS, DESTINY AIREL
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:AIREL
Last Name:DAVALOS
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 1:3140 BARBWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-1623
Mailing Address - Country:US
Mailing Address - Phone:504-261-1421
Mailing Address - Fax:
Practice Address - Street 1:2100 BELLE CHASSE HWY
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-6651
Practice Address - Country:US
Practice Address - Phone:504-367-6630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health