=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235861394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESTINATION THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2022
-----------------------------------------------------
Last Update Date | 06/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2121 ALLEN PKWY APT 1014
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77019-2424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-266-2912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3139 W HOLCOMBE BLVD STE 2296
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77025-1533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-266-2912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. MONIQUE DUNN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 346-266-2912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------