Provider Demographics
NPI:1912621251
Name:GREAT DESTINY LLC
Entity Type:Organization
Organization Name:GREAT DESTINY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIONA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRAYLOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-394-1308
Mailing Address - Street 1:5 POCOSIN CT
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-8223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:605 ALCOTT DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-4411
Practice Address - Country:US
Practice Address - Phone:803-573-2228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty