=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811222714
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DESTINEE FLOYD LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2009
-----------------------------------------------------
Last Update Date | 09/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 FITZGERALD RD STE 1
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33813-2620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-860-1621
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7707 CANFORD ST #H
-----------------------------------------------------
City | CAMBY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46113-8291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YS0200X
-----------------------------------------------------
Taxonomy Name | School Counselor
-----------------------------------------------------
License Number | 34006609A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW14069
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------