Healthcare Provider Details

I. General information

NPI: 1811672322
Provider Name (Legal Business Name): DESTINY SUPPORTIVE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 12/05/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 FAIRVIEW BLVD STE A
DELRAN NJ
08075-1475
US

IV. Provider business mailing address

1351 FAIRVIEW BLVD STE A
DELRAN NJ
08075-1475
US

V. Phone/Fax

Practice location:
  • Phone: 856-912-0712
  • Fax: 856-245-8388
Mailing address:
  • Phone: 856-912-0712
  • Fax: 856-245-8388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: NONI KENDALL
Title or Position: OWNER
Credential: LCSW
Phone: 856-912-0712