Healthcare Provider Details

I. General information

NPI: 1144744483
Provider Name (Legal Business Name): DESTINY ARIEL NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2017
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15600 19 MILE RD
CLINTON TOWNSHIP MI
48038-3502
US

IV. Provider business mailing address

42815 GARFIELD RD STE 201
CLINTON TOWNSHIP MI
48038-1143
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-8700
  • Fax:
Mailing address:
  • Phone: 586-333-5328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451024065
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: