Provider Demographics
NPI:1144554007
Name:DESTINY'S HOUSE INTENSIVE IN-HOME
Entity type:Organization
Organization Name:DESTINY'S HOUSE INTENSIVE IN-HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUHAMMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-706-3382
Mailing Address - Street 1:6060 JEFFERSON AVE
Mailing Address - Street 2:STE 9003
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23605-3014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6060 JEFFERSON AVE
Practice Address - Street 2:STE 9003
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23605-3014
Practice Address - Country:US
Practice Address - Phone:757-706-3382
Practice Address - Fax:757-706-3383
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESTINY'S HOUSE RESIDENTIAL SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA990253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA990OtherDMHMRSAS