Healthcare Provider Details

I. General information

NPI: 1528626413
Provider Name (Legal Business Name): DESTINEE MULCAHY MSCJ, LADCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 DORCHESTER AVE
DORCHESTER MA
02124-5607
US

IV. Provider business mailing address

660 OCEAN AVE APT 315
REVERE MA
02151-1288
US

V. Phone/Fax

Practice location:
  • Phone: 857-496-7353
  • Fax: 617-269-2945
Mailing address:
  • Phone: 419-307-8886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.162848
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25513
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: