Healthcare Provider Details

I. General information

NPI: 1992261663
Provider Name (Legal Business Name): DESTINATION HOPE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 NW 9TH AVE STE 311
FT LAUDERDALE FL
33309-2050
US

IV. Provider business mailing address

6555 NW 9TH AVE STE 112
FT LAUDERDALE FL
33309-2048
US

V. Phone/Fax

Practice location:
  • Phone: 954-771-2091
  • Fax: 954-771-2098
Mailing address:
  • Phone: 954-771-2091
  • Fax: 954-771-2098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA WISDOM
Title or Position: CFO
Credential:
Phone: 954-771-2091