Provider Demographics
NPI:1891491668
Name:GOSS, DESTINY REBEKAH
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:REBEKAH
Last Name:GOSS
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 1:1723 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-4715
Mailing Address - Country:US
Mailing Address - Phone:479-427-9418
Mailing Address - Fax:
Practice Address - Street 1:1723 CEDAR ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-4715
Practice Address - Country:US
Practice Address - Phone:479-427-9418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician