Provider Demographics
NPI:1194584102
Name:GANT, DESTINY ALEXIS
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:ALEXIS
Last Name:GANT
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 1:26294 BRIARWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-2753
Mailing Address - Country:US
Mailing Address - Phone:951-387-0206
Mailing Address - Fax:
Practice Address - Street 1:26294 BRIARWOOD CIR
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-2753
Practice Address - Country:US
Practice Address - Phone:951-387-0206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical