Healthcare Provider Details

I. General information

NPI: 1194097733
Provider Name (Legal Business Name): COVENANT OF LOVE MARRIAGE MINISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2012
Last Update Date: 01/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2514 DENVER DR
GREENSBORO NC
27406-6304
US

IV. Provider business mailing address

2514 DENVER DR
GREENSBORO NC
27406-6304
US

V. Phone/Fax

Practice location:
  • Phone: 336-855-7912
  • Fax: 336-852-9858
Mailing address:
  • Phone: 336-855-7912
  • Fax: 336-852-9858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number0997348
License Number StateNC

VIII. Authorized Official

Name: DR. THERESA PAYNE GREENE
Title or Position: LICENSED CLINICAL PASTORAL COUNSELO
Credential: LCPC
Phone: 336-855-7912