Provider Demographics
NPI:1669177911
Name:COVENANT HOUSE INC
Entity type:Organization
Organization Name:COVENANT HOUSE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:STUKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-844-1020
Mailing Address - Street 1:251 E BRINGHURST ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-1719
Mailing Address - Country:US
Mailing Address - Phone:215-844-1020
Mailing Address - Fax:215-844-2702
Practice Address - Street 1:57 E ARMAT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-2201
Practice Address - Country:US
Practice Address - Phone:215-844-1020
Practice Address - Fax:215-844-2702
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT HOUSE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-04-04
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty