MEDICARE: DESTINY MICHELLE CULBERTSON

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	235Z00000X	Speech-Language Pathologist	SZ11223	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255022307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY MICHELLE CULBERTSON

Provider Business Mailing Address
First Line	:	1401 REED CANAL RD
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-9400
Country	:	US
Telephone Number	:	772-418-1568
Fax Number	:

Provider Business Practice Location Address
First Line	:	2625 BARNA AVE STE H
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32780-3417
Country	:	US
Telephone Number	:	321-362-4099
Fax Number	:

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

Provider Enumeration Date	:	05/18/2023
Last Update Date	:	05/18/2023

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Directions to “ DESTINY MICHELLE CULBERTSON ” Practice Location

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