Healthcare Provider Details

I. General information

NPI: 1811147309
Provider Name (Legal Business Name): COVENANT YOUTH EMPOWERMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2008
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 CHEDWORTH LN
STONE MOUNTAIN GA
30087-2118
US

IV. Provider business mailing address

1806 CHEDWORTH LN
STONE MOUNTAIN GA
30087-2118
US

V. Phone/Fax

Practice location:
  • Phone: 404-403-1253
  • Fax:
Mailing address:
  • Phone: 404-403-1253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. STEVEN ROCHE JR.
Title or Position: ADMINISTRATOR
Credential: BACHELOR DEGREE
Phone: 404-403-1253