Provider Demographics
NPI:1417956038
Name:COVENANT PSYCHOLOGICAL SERVICES, INC
Entity Type:Organization
Organization Name:COVENANT PSYCHOLOGICAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:614-863-2399
Mailing Address - Street 1:7664 SLATE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-8158
Mailing Address - Country:US
Mailing Address - Phone:614-863-2399
Mailing Address - Fax:614-863-4040
Practice Address - Street 1:7664 SLATE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-8158
Practice Address - Country:US
Practice Address - Phone:614-863-2399
Practice Address - Fax:614-863-4040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5746103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty