Healthcare Provider Details

I. General information

NPI: 1841124922
Provider Name (Legal Business Name): DESTINEE M GIBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E AVENUE J13
LANCASTER CA
93535-4049
US

IV. Provider business mailing address

333 E AVENUE J13
LANCASTER CA
93535-4049
US

V. Phone/Fax

Practice location:
  • Phone: 661-471-6230
  • Fax:
Mailing address:
  • Phone: 661-471-6230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberY1416382
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: