Organization
DESTINY SOBER LIVING
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KATHLEEN BYNUM LPC (EXECUTIVE DIRECTOR)
(602) 249-6674
Entity
Organization
Contact information
Practice address
5306 N 17TH AVE, PHOENIX, AZ 85015-3035
(602) 249-6674
(602) 926-0590
Mailing address
5306 N 17TH AVE, PHOENIX, AZ 85015-3035
(602) 249-6674
(602) 926-0590
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
BH3285
AZ
101YM0800X
Mental Health Counselor
BH3285
AZ
101YP2500X
Professional Counselor
—
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
148801
—
AZ
05
—
439095
—
AZ
05
—
925164
—
AZ
Enumeration date
02/22/2017
Last updated
02/22/2017
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