Provider Demographics
NPI:1093037566
Name:DESTINED REVISIONS, LLC
Entity Type:Organization
Organization Name:DESTINED REVISIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JOY
Authorized Official - Middle Name:JUNESE
Authorized Official - Last Name:GRIER
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:678-468-4880
Mailing Address - Street 1:2550 E WESLEY CHAPEL WAY
Mailing Address - Street 2:STE 5
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-3430
Mailing Address - Country:US
Mailing Address - Phone:678-468-4880
Mailing Address - Fax:
Practice Address - Street 1:947 BRYANT HILL RD
Practice Address - Street 2:
Practice Address - City:MARSHALLVILLE
Practice Address - State:GA
Practice Address - Zip Code:31057-3113
Practice Address - Country:US
Practice Address - Phone:678-468-4880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-24
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health