Provider Demographics
NPI:1679222715
Name:MY COVENANT PLACE BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:MY COVENANT PLACE BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LATISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-577-7307
Mailing Address - Street 1:10630 LITTLE PATUXENT PKWY STE 113
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-6225
Mailing Address - Country:US
Mailing Address - Phone:410-200-9290
Mailing Address - Fax:301-476-0078
Practice Address - Street 1:9701 APOLLO DR STE 411
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-4783
Practice Address - Country:US
Practice Address - Phone:301-577-7307
Practice Address - Fax:301-476-0076
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MY COVENANT PLACE BEHAVIORAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-23
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)