Healthcare Provider Details

I. General information

NPI: 1477381564
Provider Name (Legal Business Name): DESTINY BLACKSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5465 ABLE CT
MOBILE AL
36693-3100
US

IV. Provider business mailing address

5451 ABLE CT
MOBILE AL
36693-3100
US

V. Phone/Fax

Practice location:
  • Phone: 251-644-5938
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-363411
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: