Healthcare Provider Details

I. General information

NPI: 1972496420
Provider Name (Legal Business Name): DIVON DESTINY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4324 VERMONT AVE
ALEXANDRIA VA
22304-4922
US

IV. Provider business mailing address

4324 VERMONT AVE
ALEXANDRIA VA
22304-4922
US

V. Phone/Fax

Practice location:
  • Phone: 703-965-0739
  • Fax:
Mailing address:
  • Phone: 703-965-0739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAKAHYA EVERETT-GATLIN
Title or Position: OWNER
Credential:
Phone: 703-965-0739