Provider Demographics
NPI:1245941830
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:PRESIDENT/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:410-200-9290
Mailing Address - Street 1:10632 LITTLE PATUXENT PKWY STE 314-D
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3273
Mailing Address - Country:US
Mailing Address - Phone:410-660-9190
Mailing Address - Fax:
Practice Address - Street 1:10632 LITTLE PATUXENT PKWY STE 314-D
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3273
Practice Address - Country:US
Practice Address - Phone:410-660-9190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MY COVENANT PLACE BEHAVIORAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health