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General NPI Number Information
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NPI Number | 1669861043
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Entity Type | Organization
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Legal Business Name | CREATOR DESTINY LLC
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Dates
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Enumeration Date | 01/22/2015
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Last Update Date | 03/09/2015
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Provider Practice Location Address
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Address Line | 503 E LOYOLA DR
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City | KENNER
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State | LA
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Zip | 70065-4119
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Country | US
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Telephone | 504-220-8442
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2353
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City | KENNER
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State | LA
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Zip | 70063-2353
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Country | US
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Telephone | 504-220-8442
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | YOLANDA ANNETTE BONNER
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Credential |
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Telephone | 504-220-8442
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 4469
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 4469
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License Number State | LA
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Taxonomy #3
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 4469
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License Number State | LA
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Taxonomy #4
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4469
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License Number State | LA
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