Provider Demographics
NPI:1215521687
Name:MANIFESTED DESTINY COUNSELING
Entity type:Organization
Organization Name:MANIFESTED DESTINY COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELDER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-682-0415
Mailing Address - Street 1:120 LONGMEADOW CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-5373
Mailing Address - Country:US
Mailing Address - Phone:404-819-4295
Mailing Address - Fax:
Practice Address - Street 1:179 HANDLEY RD STE D6
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-2152
Practice Address - Country:US
Practice Address - Phone:404-819-4295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty