Provider Demographics
NPI:1063051522
Name:AVILES, DESTINY NICOLE
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:NICOLE
Last Name:AVILES
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 1:24910 THUNDER LN
Mailing Address - Street 2:
Mailing Address - City:SAINT ROBERT
Mailing Address - State:MO
Mailing Address - Zip Code:65584-3809
Mailing Address - Country:US
Mailing Address - Phone:573-586-0411
Mailing Address - Fax:
Practice Address - Street 1:496 OLD RTE 66, ST ROBERT, MO 65584
Practice Address - Street 2:
Practice Address - City:SAINT ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584-3809
Practice Address - Country:US
Practice Address - Phone:573-246-6461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician