MEDICARE: DESTINEY GORE M.ED., BCBA

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1992214142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINEY GORE M.ED., BCBA

Provider Business Mailing Address
First Line	:	181 NORTHSIDE DR
Second Line	:
City	:	LITTLE RIVER
State	:	SC
Zip	:	29566-7113
Country	:	US
Telephone Number	:	843-516-2554
Fax Number	:

Provider Business Practice Location Address
First Line	:	181 NORTHSIDE DR
Second Line	:
City	:	LITTLE RIVER
State	:	SC
Zip	:	29566-7113
Country	:	US
Telephone Number	:	843-516-2554
Fax Number	:

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

Provider Enumeration Date	:	09/20/2017
Last Update Date	:	09/18/2023

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