Provider Demographics
NPI:1538688916
Name:DOUGLAS, DESTINY FAITH
Entity Type:Individual
Prefix:MRS
First Name:DESTINY
Middle Name:FAITH
Last Name:DOUGLAS
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 1:328 JOSHUA TREE CT
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-7203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2091 SAMS ELBOW RD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29170-1114
Practice Address - Country:US
Practice Address - Phone:803-477-7136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-16
Last Update Date:2017-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist