Provider Demographics
NPI:1053487140
Name:THE COVENANT ADOLESCENT CHEMICAL DEPENDENCY TREATMENT & PREVENTION CEN
Entity Type:Organization
Organization Name:THE COVENANT ADOLESCENT CHEMICAL DEPENDENCY TREATMENT & PREVENTION CEN
Other - Org Name:THE COVENANT, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:PIAZZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-574-9000
Mailing Address - Street 1:1515 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-2906
Mailing Address - Country:US
Mailing Address - Phone:216-574-9000
Mailing Address - Fax:216-664-6534
Practice Address - Street 1:1515 W 29TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-2906
Practice Address - Country:US
Practice Address - Phone:216-574-9000
Practice Address - Fax:216-664-6534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6782251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6782Medicare UPIN