Provider Demographics
NPI:1104409523
Name:WILLIAMS, DESTANY ANNE
Entity type:Individual
Prefix:MISS
First Name:DESTANY
Middle Name:ANNE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:DESTANY
Other - Middle Name:ANNE LOZANO
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:401 N FREDERICKSBURG ST APT 1526
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-5500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 KOHLERS XING STE 240-250
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-2460
Practice Address - Country:US
Practice Address - Phone:737-843-2058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician