MEDICARE: ARISE DESTINY LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	1041C0700X	Clinical Social Worker
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	101YM0800X	Mental Health Counselor
4	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1437541877
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARISE DESTINY LLC

Provider Business Mailing Address
First Line	:	10211 MERIDALE CROSSING DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-7367
Country	:	US
Telephone Number	:	704-907-8242
Fax Number	:

Provider Business Practice Location Address
First Line	:	1935 J N PEASE PL STE 101
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-4541
Country	:	US
Telephone Number	:	704-907-8242
Fax Number	:	704-973-0694

Authorized Official
Title or Position	:	LCSW/LISW-CP
Name	:	VIVIAN AUDREY CLARK
Credential	:
Telephone Number	:	704-907-8242

Provider Enumeration Date	:	02/23/2015
Last Update Date	:	12/13/2023

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Directions to “ARISE DESTINY LLC ” Practice Location

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