1679222715 NPI number — MY COVENANT PLACE BEHAVIORAL HEALTH

Table of content: (NPI 1679222715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679222715 NPI number — MY COVENANT PLACE BEHAVIORAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MY COVENANT PLACE BEHAVIORAL HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679222715
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10630 LITTLE PATUXENT PKWY STE 113
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21044-6225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-200-9290
Provider Business Mailing Address Fax Number:
301-476-0078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9701 APOLLO DR STE 411
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20774-4783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-577-7307
Provider Business Practice Location Address Fax Number:
301-476-0076
Provider Enumeration Date:
03/23/2022

Additional Information

Authorized Official

Authorized Official Last Name:
CARTER
Authorized Official First Name:
LATISHA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
301-577-7307

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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