Provider Demographics
NPI:1053913848
Name:HALEY, DESTINE NICOLE (LMT)
Entity type:Individual
Prefix:MS
First Name:DESTINE
Middle Name:NICOLE
Last Name:HALEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 CUNAT BLVD APT 3D
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IL
Mailing Address - Zip Code:60071-8964
Mailing Address - Country:US
Mailing Address - Phone:228-343-9641
Mailing Address - Fax:
Practice Address - Street 1:170 CUNAT BLVD APT 3D
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IL
Practice Address - Zip Code:60071-8964
Practice Address - Country:US
Practice Address - Phone:228-343-9641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.021923225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist