Provider Demographics
NPI:1760688477
Name:COVENANT COUNSELING CENTER
Entity Type:Organization
Organization Name:COVENANT COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E,
Authorized Official - Last Name:TIDSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MDIV, MED, LMFT
Authorized Official - Phone:1803-673-3634
Mailing Address - Street 1:196 BRIDGECREEK DR
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-5214
Mailing Address - Country:US
Mailing Address - Phone:843-572-4217
Mailing Address - Fax:
Practice Address - Street 1:1851 DAWSON BRANCH RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-5702
Practice Address - Country:US
Practice Address - Phone:843-851-1806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2130302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization