Healthcare Provider Details

I. General information

NPI: 1710808407
Provider Name (Legal Business Name): DESTIN JOSEPH HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1362 N CASA GRANDE AVE
CASA GRANDE AZ
85122-2648
US

IV. Provider business mailing address

1362 N CASA GRANDE AVE
CASA GRANDE AZ
85122-2648
US

V. Phone/Fax

Practice location:
  • Phone: 520-316-3360
  • Fax:
Mailing address:
  • Phone: 520-316-3360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA17481
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: