Basic Information
| Provider Information | |||||||||
| NPI: | 1134723448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | DESTINY | ||||||||
| MiddleName: | MARIAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5009 BROWN DR | ||||||||
| Address2: | |||||||||
| City: | KAILUA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967346280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3478844758 | ||||||||
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| Practice Location | |||||||||
| Address1: | 905 KALANIANAOLE HWY SPC 5001 | ||||||||
| Address2: | |||||||||
| City: | KAILUA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967344669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082472973 | ||||||||
| FaxNumber: | 8084273472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2020 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 000043013627 | 01 | NC | DL | OTHER |