MEDICARE: DESTINATION GREATNESS-GEORGIA, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor
3	103TC1900X	Counseling Psychologist
4	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1225582562
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTINATION GREATNESS-GEORGIA, LLC

Provider Business Mailing Address
First Line	:	PO BOX 29144
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30359-0144
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3343 PEACHTREE RD NE STE 145-1058
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30326-1085
Country	:	US
Telephone Number	:	800-647-3345
Fax Number	:	866-923-0754

Authorized Official
Title or Position	:	CEO
Name	:	SHANNA AMANDA JEFFERSON
Credential	:
Telephone Number	:	800-647-3345

Provider Enumeration Date	:	08/03/2016
Last Update Date	:	02/10/2021

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