Healthcare Provider Details

I. General information

NPI: 1720361447
Provider Name (Legal Business Name): COVENANT HOUSE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E BRINGHURST ST
PHILADELPHIA PA
19144-1719
US

IV. Provider business mailing address

251 E BRINGHURST ST
PHILADELPHIA PA
19144-1719
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 Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number032220
License Number StatePA

VIII. Authorized Official

Name: DR. SUSAN DENISE STUKES
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 215-844-1020