Provider Demographics
NPI:1710348933
Name:CORMIER, DESTONIE DAWN
Entity Type:Individual
Prefix:
First Name:DESTONIE
Middle Name:DAWN
Last Name:CORMIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DESTONIE
Other - Middle Name:DAWN
Other - Last Name:KIMPTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:4 FULLER ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA BAY
Mailing Address - State:NY
Mailing Address - Zip Code:13607-1316
Mailing Address - Country:US
Mailing Address - Phone:315-482-1256
Mailing Address - Fax:315-482-4911
Practice Address - Street 1:4 FULLER ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA BAY
Practice Address - State:NY
Practice Address - Zip Code:13607-1316
Practice Address - Country:US
Practice Address - Phone:315-482-1256
Practice Address - Fax:315-482-4911
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093084104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker