Healthcare Provider Details

I. General information

NPI: 1235817024
Provider Name (Legal Business Name): DESTINEE MEZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6409 E MILL PLAIN BLVD
VANCOUVER WA
98661-7454
US

IV. Provider business mailing address

11301 NE 7TH ST APT J09
VANCOUVER WA
98684-4946
US

V. Phone/Fax

Practice location:
  • Phone: 360-718-8376
  • Fax:
Mailing address:
  • Phone: 805-235-5850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: