Provider Demographics
NPI:1215374228
Name:DESTINATION GREATNESS, PLLC
Entity Type:Organization
Organization Name:DESTINATION GREATNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNA
Authorized Official - Middle Name:AMANDA
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, CFSW, LCSW
Authorized Official - Phone:919-794-5284
Mailing Address - Street 1:2530 MERIDIAN PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-5273
Mailing Address - Country:US
Mailing Address - Phone:919-794-5284
Mailing Address - Fax:866-923-0754
Practice Address - Street 1:2530 MERIDIAN PKWY STE 300
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-5273
Practice Address - Country:US
Practice Address - Phone:919-794-5284
Practice Address - Fax:866-923-0754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-30
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1215374228Medicaid