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General NPI Number Information
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NPI Number | 1275833774
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Entity Type | Organization
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Legal Business Name | DESTINI THERAPEUTIC SERVICES
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Dates
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Enumeration Date | 10/30/2010
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Last Update Date | 02/14/2014
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Provider Practice Location Address
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Address Line | 3152 HALIFAX RD STE E
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City | SOUTH BOSTON
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State | VA
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Zip | 24592-4906
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Country | US
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Telephone | 434-575-0855
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Fax | 434-207-6164
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Provider Business Mailing Address
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Address Line | 3152-E HALIFAX ROAD E
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City | SOUTH BOSTON
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State | VA
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Zip | 24592-4906
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Country | US
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Telephone | 434-575-0855
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JENNIFER MANGUM
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Credential |
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Telephone | 434-575-0855
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #3
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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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Taxonomy #4
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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