Provider Demographics
NPI:1841897485
Name:MALICOAT, DESTANI SHYNE
Entity type:Individual
Prefix:
First Name:DESTANI
Middle Name:SHYNE
Last Name:MALICOAT
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 1:3446 RUSTIC HOLW
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-1618
Mailing Address - Country:US
Mailing Address - Phone:405-756-6225
Mailing Address - Fax:
Practice Address - Street 1:6803 S WESTERN AVE STE 404
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-1814
Practice Address - Country:US
Practice Address - Phone:405-208-4469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator