Healthcare Provider Details

I. General information

NPI: 1629642715
Provider Name (Legal Business Name): DESTINY ARIAL PATE CROSS LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E LOOP RD # 301A
WHEATON IL
60189-1938
US

IV. Provider business mailing address

1743 MCCORMICK LN
HANOVER PARK IL
60133-5999
US

V. Phone/Fax

Practice location:
  • Phone: 630-428-7890
  • Fax:
Mailing address:
  • Phone: 630-991-8918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150108096
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: