MEDICARE: DESTINI LOVE

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	3600C	AL

General Provider Information

NPI Number	:	1629469168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINI LOVE

Provider Business Mailing Address
First Line	:	6793 DEER FOOT DR
Second Line	:
City	:	PINSON
State	:	AL
Zip	:	35126-6202
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	181 W VALLEY AVE
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35209-3691
Country	:	US
Telephone Number	:	205-675-6592
Fax Number	:	205-278-5526

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

Provider Enumeration Date	:	02/05/2015
Last Update Date	:	02/05/2015

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Directions to “ DESTINI LOVE ” Practice Location

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