Individual
DESTINY PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
21415 CIVIC CENTER DR STE 209, SOUTHFIELD, MI 48076-3943
(248) 703-2889
Mailing address
21415 CIVIC CENTER DR STE 209, SOUTHFIELD, MI 48076-3943
(248) 703-2889
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
7501000917
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
7501000917
STATE OF MICHIGAN LICENSING BOARD NUMBER
MI
Enumeration date
01/15/2015
Last updated
01/15/2015
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