Provider Demographics
NPI:1982330353
Name:DESTINY THERAPEUTIC SERVICES LLC
Entity Type:Organization
Organization Name:DESTINY THERAPEUTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LARONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHATMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-359-1267
Mailing Address - Street 1:4186 OKEECHOBEE ROAD
Mailing Address - Street 2:SUITE 77
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947
Mailing Address - Country:US
Mailing Address - Phone:772-359-1267
Mailing Address - Fax:772-264-8224
Practice Address - Street 1:4186 OKEECHOBEE ROAD
Practice Address - Street 2:SUITE 77
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947
Practice Address - Country:US
Practice Address - Phone:772-359-1267
Practice Address - Fax:772-264-8224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111187900Medicaid