Provider Demographics
NPI:1679010938
Name:DESTIN, RANDY AUGUSTEEN (CASAC)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:AUGUSTEEN
Last Name:DESTIN
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-6305
Mailing Address - Country:US
Mailing Address - Phone:718-466-8438
Mailing Address - Fax:718-731-2453
Practice Address - Street 1:1910 ARTHUR AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-6305
Practice Address - Country:US
Practice Address - Phone:718-466-8438
Practice Address - Fax:718-731-2453
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17516101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)