Healthcare Provider Details

I. General information

NPI: 1124603766
Provider Name (Legal Business Name): DESTINY J T HILLIARD-THOMAS LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 03/04/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W 40TH ST STE 206
BALTIMORE MD
21211-2108
US

IV. Provider business mailing address

12358 BONFIRE DR
REISTERSTOWN MD
21136-1712
US

V. Phone/Fax

Practice location:
  • Phone: 410-842-6055
  • Fax:
Mailing address:
  • Phone: 732-533-3806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLC13621
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC13621
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC13621
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: