Healthcare Provider Details

I. General information

NPI: 1891641684
Provider Name (Legal Business Name): DESTANY A MADDIES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2026
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 SIDE SADDLE CIR
SAN JACINTO CA
92582-3353
US

IV. Provider business mailing address

1459 SIDE SADDLE CIR
SAN JACINTO CA
92582-3353
US

V. Phone/Fax

Practice location:
  • Phone: 951-441-4795
  • Fax:
Mailing address:
  • Phone: 951-441-4795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: