Healthcare Provider Details

I. General information

NPI: 1346398914
Provider Name (Legal Business Name): DESTINY PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5319 SENTRY LN
WOODBRIDGE VA
22193-3431
US

IV. Provider business mailing address

17964 SWANS CREEK LN
DUMFRIES VA
22026-4526
US

V. Phone/Fax

Practice location:
  • Phone: 703-371-3421
  • Fax:
Mailing address:
  • Phone: 703-371-3421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number570
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number570
License Number StateVA

VIII. Authorized Official

Name: MRS. DEBORAH COLEMAN ROUNDTREE
Title or Position: CEO
Credential: MA
Phone: 703-371-3421