Provider Demographics
NPI:1851855704
Name:DESTINASSE, MALEN
Entity Type:Individual
Prefix:
First Name:MALEN
Middle Name:
Last Name:DESTINASSE
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 1:22267 SW 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-4409
Mailing Address - Country:US
Mailing Address - Phone:772-877-9261
Mailing Address - Fax:
Practice Address - Street 1:2640 FOREST HILL BLVD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-5931
Practice Address - Country:US
Practice Address - Phone:772-877-9261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator