Provider Demographics
NPI:1790658532
Name:CLARKE, DESTINY RAVEN
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:RAVEN
Last Name:CLARKE
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 1:6131 CHAMBERLAIN PL APT 202
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-7209
Mailing Address - Country:US
Mailing Address - Phone:910-585-6206
Mailing Address - Fax:
Practice Address - Street 1:6131 CHAMBERLAIN PL APT 202
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7209
Practice Address - Country:US
Practice Address - Phone:910-585-6206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician