Provider Demographics
NPI:1558803353
Name:ATTERBURY, DESTIN TROY SR
Entity Type:Individual
Prefix:MR
First Name:DESTIN
Middle Name:TROY
Last Name:ATTERBURY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 REDONDO AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2325
Mailing Address - Country:US
Mailing Address - Phone:562-256-2900
Mailing Address - Fax:562-290-0074
Practice Address - Street 1:2600 REDONDO AVE FL 3
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2325
Practice Address - Country:US
Practice Address - Phone:562-256-2900
Practice Address - Fax:562-290-0074
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW86283101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1041C0700XMedicaid
CA00000000000000OtherUNKNOWN