Healthcare Provider Details

I. General information

NPI: 1669861043
Provider Name (Legal Business Name): CREATOR DESTINY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 E LOYOLA DR
KENNER LA
70065-4119
US

IV. Provider business mailing address

PO BOX 2353
KENNER LA
70063-2353
US

V. Phone/Fax

Practice location:
  • Phone: 504-220-8442
  • Fax:
Mailing address:
  • Phone: 504-220-8442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number4469
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4469
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4469
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number4469
License Number StateLA

VIII. Authorized Official

Name: YOLANDA ANNETTE BONNER
Title or Position: OWNER
Credential:
Phone: 504-220-8442