Provider Demographics
NPI:1932651072
Name:UNIQUE DESTINY INC
Entity Type:Organization
Organization Name:UNIQUE DESTINY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SANDTRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-924-5560
Mailing Address - Street 1:203 VINE ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-3346
Mailing Address - Country:US
Mailing Address - Phone:404-924-5560
Mailing Address - Fax:
Practice Address - Street 1:7117 WALTON HL
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-7112
Practice Address - Country:US
Practice Address - Phone:404-924-5560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC004555251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health