Provider Demographics
NPI:1518661776
Name:SLATER, DESTINY
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:SLATER
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 1:19616 BLOOM ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-2464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19616 BLOOM ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-2464
Practice Address - Country:US
Practice Address - Phone:313-689-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst