Healthcare Provider Details

I. General information

NPI: 1043864432
Provider Name (Legal Business Name): DESTINY LACARA MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 02/20/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3485 N DESERT DR STE 105
EAST POINT GA
30344-5724
US

IV. Provider business mailing address

11009 SOUTHWOOD DR
HAMPTON GA
30228-3498
US

V. Phone/Fax

Practice location:
  • Phone: 678-724-7033
  • Fax:
Mailing address:
  • Phone: 404-831-2098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA000396
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberPCET004155
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: