Provider Demographics
NPI:1134765316
Name:MCGILL, DESTINYE NICOLE (MS)
Entity type:Individual
Prefix:
First Name:DESTINYE
Middle Name:NICOLE
Last Name:MCGILL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 N OCCIDENTAL BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-4641
Mailing Address - Country:US
Mailing Address - Phone:213-381-2931
Mailing Address - Fax:
Practice Address - Street 1:155 N OCCIDENTAL BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-4641
Practice Address - Country:US
Practice Address - Phone:213-381-2931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82095101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health