Provider Demographics
NPI:1669861043
Name:CREATOR DESTINY LLC
Entity Type:Organization
Organization Name:CREATOR DESTINY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-220-8442
Mailing Address - Street 1:PO BOX 2353
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70063-2353
Mailing Address - Country:US
Mailing Address - Phone:504-220-8442
Mailing Address - Fax:
Practice Address - Street 1:503 E LOYOLA DR
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-4119
Practice Address - Country:US
Practice Address - Phone:504-220-8442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4469101YM0800X, 101YP2500X, 251S00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty