Healthcare Provider Details

I. General information

NPI: 1164853669
Provider Name (Legal Business Name): MY COVENANT PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 APOLLO DR STE 4114TH
LARGO MD
20774-4783
US

IV. Provider business mailing address

10630 LITTLE PATUXENT PKWY STE 113
COLUMBIA MD
21044-6225
US

V. Phone/Fax

Practice location:
  • Phone: 301-577-7307
  • Fax: 301-476-0076
Mailing address:
  • Phone: 410-200-9290
  • Fax: 301-476-0076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

# 1
Identifier19125M99
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name: MS. LATISHA CARTER
Title or Position: CEO/EXECUTIVE DIRECTOR
Credential:
Phone: 301-577-7307