Provider Demographics
NPI:1740937895
Name:TRANSFORMATIVE DESTINY PLLC
Entity type:Organization
Organization Name:TRANSFORMATIVE DESTINY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:419-577-0361
Mailing Address - Street 1:208 CALLANDALE LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-9496
Mailing Address - Country:US
Mailing Address - Phone:419-577-0361
Mailing Address - Fax:
Practice Address - Street 1:4801 GLENWOOD AVE STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-3857
Practice Address - Country:US
Practice Address - Phone:419-577-0361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)