Healthcare Provider Details

I. General information

NPI: 1861227415
Provider Name (Legal Business Name): DESTINY S LYALS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 NW 64TH TER STE A
GAINESVILLE FL
32605-4261
US

IV. Provider business mailing address

6941 POWELL RD
WILDWOOD FL
34785-4247
US

V. Phone/Fax

Practice location:
  • Phone: 396-906-9062
  • Fax:
Mailing address:
  • Phone: 352-461-6185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH24195
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: