MEDICARE: MARIETHA DESTIN LMFT

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	101YS0200X	School Counselor
2	222Q00000X	Developmental Therapist
3	106H00000X	Marriage & Family Therapist	MT2998	FL
4	101Y00000X	Counselor	MT2998	FL

General Provider Information

NPI Number	:	1811295959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIETHA DESTIN LMFT

Provider Business Mailing Address
First Line	:	211 LITHIA PINECREST RD
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-5307
Country	:	US
Telephone Number	:	813-720-5191
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 LITHIA PINECREST RD
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-5307
Country	:	US
Telephone Number	:	813-720-5191
Fax Number	:

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

Provider Enumeration Date	:	03/13/2011
Last Update Date	:	03/09/2015

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