MEDICARE: DESTANE GOODS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1174478515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTANE GOODS

Provider Business Mailing Address
First Line	:	2550 N HOLLYWOOD WAY STE 301
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-5025
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2219 YORK RD STE 100
Second Line	:
City	:	TIMONIUM
State	:	MD
Zip	:	21093-3140
Country	:	US
Telephone Number	:	866-727-8274
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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Directions to “ DESTANE GOODS ” Practice Location

Language	Start Address	Practice Location

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