Provider Demographics
NPI:1629567417
Name:DESTIN, SHELLON
Entity Type:Individual
Prefix:
First Name:SHELLON
Middle Name:
Last Name:DESTIN
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 1:974 SCHENECTADY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-4212
Mailing Address - Country:US
Mailing Address - Phone:929-369-8121
Mailing Address - Fax:
Practice Address - Street 1:974 SCHENECTADY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-4212
Practice Address - Country:US
Practice Address - Phone:929-369-8121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management