Provider Demographics
NPI:1497923312
Name:COVENANT COUNSELING CENTER
Entity Type:Organization
Organization Name:COVENANT COUNSELING CENTER
Other - Org Name:SIX RIVERS COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:TILLERY
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:530-245-5805
Mailing Address - Street 1:393 PARK MARINA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001
Mailing Address - Country:US
Mailing Address - Phone:530-245-5805
Mailing Address - Fax:530-245-0340
Practice Address - Street 1:3960 WALNUT DRIVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503
Practice Address - Country:US
Practice Address - Phone:707-268-8722
Practice Address - Fax:707-268-0218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125001555251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health