MEDICARE: MY COVENANT PLACE BEHAVIORAL HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1326704073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY COVENANT PLACE BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	10630 LITTLE PATUXENT PKWY STE 314D
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21044-6216
Country	:	US
Telephone Number	:	410-200-9290
Fax Number	:

Provider Business Practice Location Address
First Line	:	9750 APOLLO DRIVE
Second Line	:	SUITE B
City	:	LARGO
State	:	MD
Zip	:	20774-2077
Country	:	US
Telephone Number	:	301-577-7307
Fax Number	:	301-476-0076

Authorized Official
Title or Position	:	CEO/EXECUTIVE DIRECTOR
Name	:	MS. LATISHA CARTER
Credential	:
Telephone Number	:	301-577-7307

Provider Enumeration Date	:	11/16/2021
Last Update Date	:	03/16/2022

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