Provider Demographics
NPI:1255022307
Name:CULBERTSON, DESTINY MICHELLE
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:MICHELLE
Last Name:CULBERTSON
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 1:1401 REED CANAL RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-9400
Mailing Address - Country:US
Mailing Address - Phone:772-418-1568
Mailing Address - Fax:
Practice Address - Street 1:2625 BARNA AVE STE H
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-3417
Practice Address - Country:US
Practice Address - Phone:321-362-4099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ11223235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist