MEDICARE: DESTINED PATH THERAPY SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1023959749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTINED PATH THERAPY SERVICES LLC

Provider Business Mailing Address
First Line	:	11009 SOUTHWOOD DR
Second Line	:
City	:	HAMPTON
State	:	GA
Zip	:	30228-3498
Country	:	US
Telephone Number	:	404-913-2097
Fax Number	:

Provider Business Practice Location Address
First Line	:	11009 SOUTHWOOD DR
Second Line	:
City	:	HAMPTON
State	:	GA
Zip	:	30228-3498
Country	:	US
Telephone Number	:	404-913-2097
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DESTINY MACK
Credential	:	M.S., CCC-SLP
Telephone Number	:	404-913-2097

Provider Enumeration Date	:	04/06/2026
Last Update Date	:	04/06/2026

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Directions to “DESTINED PATH THERAPY SERVICES LLC ” Practice Location

Language	Start Address	Practice Location

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