Provider Demographics
NPI:1558874081
Name:FORDHAM, DESTINY ANTANAY-LAMARRIA (BS)
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:ANTANAY-LAMARRIA
Last Name:FORDHAM
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35425 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-9800
Mailing Address - Country:US
Mailing Address - Phone:734-467-7600
Mailing Address - Fax:
Practice Address - Street 1:35425 W. MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184
Practice Address - Country:US
Practice Address - Phone:734-467-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No156F00000XEye and Vision Services ProvidersTechnician/Technologist