Provider Demographics
NPI:1811147309
Name:COVENANT YOUTH EMPOWERMENT LLC
Entity type:Organization
Organization Name:COVENANT YOUTH EMPOWERMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCHE
Authorized Official - Suffix:JR
Authorized Official - Credentials:BACHELOR DEGREE
Authorized Official - Phone:404-403-1253
Mailing Address - Street 1:1806 CHEDWORTH LN
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-2118
Mailing Address - Country:US
Mailing Address - Phone:404-403-1253
Mailing Address - Fax:
Practice Address - Street 1:1806 CHEDWORTH LN
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-2118
Practice Address - Country:US
Practice Address - Phone:404-403-1253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-22
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty