Provider Demographics
NPI:1811295959
Name:DESTIN, MARIETHA (LMFT)
Entity type:Individual
Prefix:
First Name:MARIETHA
Middle Name:
Last Name:DESTIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 LITHIA PINECREST RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5307
Mailing Address - Country:US
Mailing Address - Phone:813-720-5191
Mailing Address - Fax:
Practice Address - Street 1:211 LITHIA PINECREST RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5307
Practice Address - Country:US
Practice Address - Phone:813-720-5191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-13
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X, 222Q00000X
FLMT2998106H00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist