MEDICARE: DESTINI FOUNTAIN

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
1	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst		TX

General Provider Information

NPI Number	:	1689282832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINI FOUNTAIN

Provider Business Mailing Address
First Line	:	919 MEDICAL DR STE 1200
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75013-5756
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	919 MEDICAL DR STE 1200
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75013-5756
Country	:	US
Telephone Number	:	214-505-9984
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2020
Last Update Date	:	12/10/2024

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Directions to “ DESTINI FOUNTAIN ” Practice Location

Language	Start Address	Practice Location

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