Healthcare Provider Details

I. General information

NPI: 1497923312
Provider Name (Legal Business Name): COVENANT COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3960 WALNUT DRIVE
EUREKA CA
95503
US

IV. Provider business mailing address

393 PARK MARINA CIRCLE
REDDING CA
96001
US

V. Phone/Fax

Practice location:
  • Phone: 707-268-8722
  • Fax: 707-268-0218
Mailing address:
  • Phone: 530-245-5805
  • Fax: 530-245-0340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number125001555
License Number StateCA

VIII. Authorized Official

Name: MR. JOHN W TILLERY
Title or Position: EXECUTIVE DIRECTOR
Credential: CPA
Phone: 530-245-5805