MEDICARE: DESTINATION THERAPY PLLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1235861394
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTINATION THERAPY PLLC

Provider Business Mailing Address
First Line	:	3139 W HOLCOMBE BLVD STE 2296
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-1533
Country	:	US
Telephone Number	:	346-266-2912
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 ALLEN PKWY APT 1014
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77019-2424
Country	:	US
Telephone Number	:	346-266-2912
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MONIQUE DUNN
Credential	:	LCSW
Telephone Number	:	346-266-2912

Provider Enumeration Date	:	06/28/2022
Last Update Date	:	06/28/2022

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