Provider Demographics
NPI:1043858566
Name:SQUIRES, DESTINY MARIE SIMONE
Entity type:Individual
Prefix:MS
First Name:DESTINY
Middle Name:MARIE SIMONE
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 NOSTRAND AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-3029
Mailing Address - Country:US
Mailing Address - Phone:718-258-1714
Mailing Address - Fax:
Practice Address - Street 1:2233 NOSTRAND AVE STE 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-3029
Practice Address - Country:US
Practice Address - Phone:718-258-1714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty