Provider Demographics
NPI:1740900778
Name:DESTINY LEAGUE
Entity type:Organization
Organization Name:DESTINY LEAGUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OBI
Authorized Official - Middle Name:
Authorized Official - Last Name:HERBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-644-6886
Mailing Address - Street 1:8201 CORPORATE DR STE 630
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-2371
Mailing Address - Country:US
Mailing Address - Phone:410-213-5494
Mailing Address - Fax:
Practice Address - Street 1:8201 CORPORATE DR STE 630
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-2371
Practice Address - Country:US
Practice Address - Phone:410-213-5494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESTINY LEAGUE FOUNDATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)