Provider Demographics
NPI:1164967527
Name:COVENANT COUNSELING
Entity Type:Organization
Organization Name:COVENANT COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DBH
Authorized Official - Phone:760-241-6044
Mailing Address - Street 1:851 S MOUNT VERNON AVE STE 7A
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3926
Mailing Address - Country:US
Mailing Address - Phone:760-241-6044
Mailing Address - Fax:760-820-2704
Practice Address - Street 1:851 S MOUNT VERNON AVE STE 7A
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3926
Practice Address - Country:US
Practice Address - Phone:760-241-6044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-21
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALPCC2784251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty