Healthcare Provider Details

I. General information

NPI: 1699506576
Provider Name (Legal Business Name): COVENANT HOUSE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E CHELTEN AVE FL 3
PHILADELPHIA PA
19144-6701
US

IV. Provider business mailing address

251 E BRINGHURST ST
PHILADELPHIA PA
19144-1799
US

V. Phone/Fax

Practice location:
  • Phone: 215-844-1020
  • Fax: 215-844-2702
Mailing address:
  • Phone: 215-844-1020
  • Fax: 215-844-2702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CAROLYN RICHARDSON
Title or Position: DIRECTOR, REIMBURSEMENT
Credential:
Phone: 215-844-1020