Healthcare Provider Details

I. General information

NPI: 1760688477
Provider Name (Legal Business Name): COVENANT COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 DAWSON BRANCH RD
SUMMERVILLE SC
29483-5702
US

IV. Provider business mailing address

196 BRIDGECREEK DR
GOOSE CREEK SC
29445-5214
US

V. Phone/Fax

Practice location:
  • Phone: 843-851-1806
  • Fax:
Mailing address:
  • Phone: 843-572-4217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number2130
License Number StateSC

VIII. Authorized Official

Name: MR. MARK E, TIDSWORTH
Title or Position: CONSULTING DIRECTOR
Credential: MDIV., MED, LMFT
Phone: 18036733634