Provider Demographics
NPI:1508586520
Name:JOHN, DESTINY
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:JOHN
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 1:710 S 8TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-4634
Mailing Address - Country:US
Mailing Address - Phone:409-299-9460
Mailing Address - Fax:409-299-9433
Practice Address - Street 1:710 S 8TH ST STE B
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4634
Practice Address - Country:US
Practice Address - Phone:409-299-9460
Practice Address - Fax:409-299-9433
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXRBT-22-232309OtherBACB