Provider Demographics
NPI:1184321556
Name:DIVINE DESTINY BEHAVIOR HEALTH, LLC
Entity type:Organization
Organization Name:DIVINE DESTINY BEHAVIOR HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:JONES
Authorized Official - Last Name:FULTON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:843-401-9217
Mailing Address - Street 1:PO BOX 978
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-0978
Mailing Address - Country:US
Mailing Address - Phone:843-401-9217
Mailing Address - Fax:
Practice Address - Street 1:19 EMIEL C. BAKER ROAD
Practice Address - Street 2:
Practice Address - City:SALTERS
Practice Address - State:SC
Practice Address - Zip Code:29590
Practice Address - Country:US
Practice Address - Phone:843-401-9217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health