Healthcare Provider Details

I. General information

NPI: 1245886761
Provider Name (Legal Business Name): DESTINY SKYE PHERNETTON M.S ., BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 WALL ST STE 1000
MADISON WI
53718-7983
US

IV. Provider business mailing address

901 WHALEN RD STE A
VERONA WI
53593-1766
US

V. Phone/Fax

Practice location:
  • Phone: 855-444-5664
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1250-140
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-90748
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: