Provider Demographics
NPI:1104365287
Name:DESTINY SOBER LIVING
Entity Type:Organization
Organization Name:DESTINY SOBER LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BYNUM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:602-249-6674
Mailing Address - Street 1:5306 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-3035
Mailing Address - Country:US
Mailing Address - Phone:602-249-6674
Mailing Address - Fax:602-926-0590
Practice Address - Street 1:5306 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3035
Practice Address - Country:US
Practice Address - Phone:602-249-6674
Practice Address - Fax:602-926-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH3285101YA0400X, 101YM0800X
AZ101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ439095Medicaid
AZ148801Medicaid
AZ925164Medicaid