Healthcare Provider Details

I. General information

NPI: 1558010603
Provider Name (Legal Business Name): MY COVENANT PLACE BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 01/10/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 APOLLO DR STE 411
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: 443-759-3355
  • Fax: 301-476-0076
Mailing address:
  • Phone: 410-200-9192
  • Fax: 301-476-0076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: LATISHA CARTER
Title or Position: CEO
Credential:
Phone: 301-577-7307