Provider Demographics
NPI:1902559222
Name:MARTINI, DESTIN RAE SR (SUDPT)
Entity Type:Individual
Prefix:
First Name:DESTIN
Middle Name:RAE
Last Name:MARTINI
Suffix:SR
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SE WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-3058
Mailing Address - Country:US
Mailing Address - Phone:360-748-4776
Mailing Address - Fax:
Practice Address - Street 1:500 SE WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3058
Practice Address - Country:US
Practice Address - Phone:360-748-4776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61210725101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2077844Medicaid