Provider Demographics
NPI:1043864432
Name:MACK, DESTINY LACARA
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:LACARA
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11009 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-3498
Mailing Address - Country:US
Mailing Address - Phone:404-831-2098
Mailing Address - Fax:
Practice Address - Street 1:160 ROBERTS DR
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-3302
Practice Address - Country:US
Practice Address - Phone:770-473-2905
Practice Address - Fax:770-473-2913
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLPA0003962355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant