Healthcare Provider Details

I. General information

NPI: 1811372212
Provider Name (Legal Business Name): COVENANT HOUSE DC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 07/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 MISSISSIPPI AVE, SE
WASHINGTON DC
20020
US

IV. Provider business mailing address

2001 MISSISSIPPI AVE SE
WASHINGTON DC
20020-6116
US

V. Phone/Fax

Practice location:
  • Phone: 202-610-9603
  • Fax:
Mailing address:
  • Phone: 202-610-9603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateDC
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateDC
# 6
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number StateDC
# 7
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number StateDC
# 8
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateDC
# 9
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateDC
# 10
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateDC

VIII. Authorized Official

Name: MR. GARRETT MUSHAW
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 202-610-9603