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General NPI Number Information
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NPI Number | 1215521687
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Entity Type | Organization
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Legal Business Name | MANIFESTED DESTINY COUNSELING
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Dates
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Enumeration Date | 02/25/2021
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Last Update Date | 02/25/2021
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Provider Practice Location Address
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Address Line | 179 HANDLEY RD STE D6
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City | TYRONE
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State | GA
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Zip | 30290-2152
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Country | US
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Telephone | 404-819-4295
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Fax |
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Provider Business Mailing Address
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Address Line | 120 LONGMEADOW CT
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-5373
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Country | US
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Telephone | 404-819-4295
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | PAMELA ELDER
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Credential | LPC
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Telephone | 678-682-0415
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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