Healthcare Provider Details

I. General information

NPI: 1851722532
Provider Name (Legal Business Name): DESTINATION GREATNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2013
Last Update Date: 12/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 FLAT ST E
ALLENDALE SC
29810-5818
US

IV. Provider business mailing address

PO BOX 13273
DURHAM NC
27709-3273
US

V. Phone/Fax

Practice location:
  • Phone: 919-794-5284
  • Fax:
Mailing address:
  • Phone: 919-794-5284
  • Fax:

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 Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SHANNA A JEFFERSON
Title or Position: OWNER
Credential: MSW, CFSW, LCSW
Phone: 919-794-5284