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NPI Code Detail

MEDICARE: FREEDAH DESTINY EXAVIER MS

MEDICARE: FREEDAH DESTINY EXAVIER MS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1251B00000XCase Management Agency
2101YM0800XMental Health Counselor19949FL

General Provider Information

NPI Number : 1356749303
Entity Type Code : Individual
Provider Name (Legal Business Name) : FREEDAH DESTINY EXAVIER MS
Provider Business Mailing Address
First Line : 718 SW BYRON ST
Second Line :
City : PORT ST LUCIE
State : FL
Zip : 34983-1922
Country : US
Telephone Number : 561-906-4743
Fax Number :
Provider Business Practice Location Address
First Line : 1601 NE BRAILLE PL
Second Line :
City : JENSEN BEACH
State : FL
Zip : 34957-5345
Country : US
Telephone Number : 561-906-4743
Fax Number : 772-444-3735
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/08/2014
Last Update Date : 11/26/2024

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