Provider Demographics
NPI:1649838525
Name:THE DESTIN GROUP LLC
Entity type:Organization
Organization Name:THE DESTIN GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIAL
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:MICHELL
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-503-4634
Mailing Address - Street 1:12220 CHATTANOOGA PLZ # 208
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4865
Mailing Address - Country:US
Mailing Address - Phone:804-381-8337
Mailing Address - Fax:
Practice Address - Street 1:8819 PEEBLE BEACH COURT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-2667
Practice Address - Country:US
Practice Address - Phone:804-381-8337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA601208245Medicaid