Healthcare Provider Details

I. General information

NPI: 1104365287
Provider Name (Legal Business Name): DESTINY SOBER LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5306 N 17TH AVE
PHOENIX AZ
85015-3035
US

IV. Provider business mailing address

5306 N 17TH AVE
PHOENIX AZ
85015-3035
US

V. Phone/Fax

Practice location:
  • Phone: 602-249-6674
  • Fax: 602-926-0590
Mailing address:
  • Phone: 602-249-6674
  • Fax: 602-926-0590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBH3285
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBH3285
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateAZ

VIII. Authorized Official

Name: KATHLEEN BYNUM
Title or Position: EXECUTIVE DIRECTOR
Credential: LPC
Phone: 602-249-6674