Provider Demographics
NPI:1629376603
Name:DESTINY INCORPORATED
Entity type:Organization
Organization Name:DESTINY INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JONNA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:MCCLURE
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:719-564-0163
Mailing Address - Street 1:1339 S PUEBLO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005
Mailing Address - Country:US
Mailing Address - Phone:719-564-0163
Mailing Address - Fax:719-564-0193
Practice Address - Street 1:1339 S PUEBLO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005
Practice Address - Country:US
Practice Address - Phone:719-564-0163
Practice Address - Fax:719-564-0193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-01
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO99500221Medicaid