Provider Demographics
NPI:1992043707
Name:WILTSHIRE, DESTINIE
Entity Type:Individual
Prefix:
First Name:DESTINIE
Middle Name:
Last Name:WILTSHIRE
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 1:14809 STATE HIGHWAY 116
Mailing Address - Street 2:
Mailing Address - City:COLCORD
Mailing Address - State:OK
Mailing Address - Zip Code:74338-2609
Mailing Address - Country:US
Mailing Address - Phone:918-776-7305
Mailing Address - Fax:
Practice Address - Street 1:201 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WATTS
Practice Address - State:OK
Practice Address - Zip Code:74964
Practice Address - Country:US
Practice Address - Phone:918-442-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK100708280C101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1003988726OtherNPI