Provider Demographics
NPI:1689001117
Name:DESTINED TO REIGN COUNSELING SERVICES, L.L.C.
Entity Type:Organization
Organization Name:DESTINED TO REIGN COUNSELING SERVICES, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/LICENSED PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DAMIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MA,LPC, PHD,ABD
Authorized Official - Phone:770-875-6760
Mailing Address - Street 1:2224 LAKE HARBIN RD
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-1907
Mailing Address - Country:US
Mailing Address - Phone:404-441-7918
Mailing Address - Fax:
Practice Address - Street 1:2224 LAKE HARBIN RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-1907
Practice Address - Country:US
Practice Address - Phone:404-441-7918
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005815101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134017AMedicaid