Provider Demographics
NPI:1598352940
Name:THOMAS, DESTINEE
Entity Type:Individual
Prefix:
First Name:DESTINEE
Middle Name:
Last Name:THOMAS
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 1:17518 PAINTER LOOP RD NE
Mailing Address - Street 2:
Mailing Address - City:HUBBARD
Mailing Address - State:OR
Mailing Address - Zip Code:97032-9757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17518 PAINTER LOOP RD NE
Practice Address - Street 2:
Practice Address - City:HUBBARD
Practice Address - State:OR
Practice Address - Zip Code:97032-9757
Practice Address - Country:US
Practice Address - Phone:360-904-0771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer