MEDICARE: DESTINY ISHMAN

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		GA

General Provider Information

NPI Number	:	1912836594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY ISHMAN

Provider Business Mailing Address
First Line	:	3753 AUSTELL RD APT 5310
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30106-2240
Country	:	US
Telephone Number	:	917-946-6123
Fax Number	:

Provider Business Practice Location Address
First Line	:	3993 LAWRENCEVILLE HWY NW STE 110
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-2831
Country	:	US
Telephone Number	:	917-946-6123
Fax Number	:

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

Provider Enumeration Date	:	05/18/2026
Last Update Date	:	05/18/2026

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Directions to “ DESTINY ISHMAN ” Practice Location

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