Provider Demographics
NPI:1174404719
Name:FORGE, DESTINY DANIELLE (LPC)
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:DANIELLE
Last Name:FORGE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 E CENTRAL AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3344
Mailing Address - Country:US
Mailing Address - Phone:316-648-4673
Mailing Address - Fax:
Practice Address - Street 1:2501 E CENTRAL AVE STE 2
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3344
Practice Address - Country:US
Practice Address - Phone:316-648-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05175101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional