Provider Demographics
NPI:1346398914
Name:DESTINY PLACE LLC
Entity Type:Organization
Organization Name:DESTINY PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:COLEMAN
Authorized Official - Last Name:ROUNDTREE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:703-371-3421
Mailing Address - Street 1:17964 SWANS CREEK LN
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22026-4526
Mailing Address - Country:US
Mailing Address - Phone:703-371-3421
Mailing Address - Fax:
Practice Address - Street 1:5319 SENTRY LN
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-3431
Practice Address - Country:US
Practice Address - Phone:703-371-3421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA570251C00000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services
Not Answered320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities