Provider Demographics
NPI:1508036054
Name:COVENANT 21ST CENTURY MINISTRIES, INC
Entity Type:Organization
Organization Name:COVENANT 21ST CENTURY MINISTRIES, INC
Other - Org Name:COVENANT PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PORTIA
Authorized Official - Middle Name:DENEEN
Authorized Official - Last Name:RAWLES
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:757-493-2912
Mailing Address - Street 1:5301 PROVIDENCE RD
Mailing Address - Street 2:SUITE 20
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4128
Mailing Address - Country:US
Mailing Address - Phone:757-493-2912
Mailing Address - Fax:757-493-2913
Practice Address - Street 1:260 FILBERT ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4410
Practice Address - Country:US
Practice Address - Phone:757-493-2912
Practice Address - Fax:757-493-2913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA80714001320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1508036054Medicaid