Provider Demographics
NPI:1376141432
Name:KING, DESTINY BROOKS (MS, LPC,)
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:BROOKS
Last Name:KING
Suffix:
Gender:F
Credentials:MS, LPC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BIRDIE CT
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-9104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5245
Practice Address - Country:US
Practice Address - Phone:912-225-3769
Practice Address - Fax:888-241-9172
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011783101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional