MEDICARE: JOURNEY TO YOUR DESTINY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578223954
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOURNEY TO YOUR DESTINY, PLLC

Provider Business Mailing Address
First Line	:	6241 SOUTH BLVD UNIT 241883
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28224-0327
Country	:	US
Telephone Number	:	704-430-5547
Fax Number	:	704-327-5547

Provider Business Practice Location Address
First Line	:	2404 SANDY RIVER LANE APT 103
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273
Country	:	US
Telephone Number	:	910-431-6163
Fax Number	:	704-327-5547

Authorized Official
Title or Position	:	PSYCHOTHERAPIST/ CEO
Name	:	DONNETTA L EVANS
Credential	:	LCSW
Telephone Number	:	910-431-6163

Provider Enumeration Date	:	12/27/2021
Last Update Date	:	02/09/2022

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