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General NPI Number Information
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NPI Number | 1508036054
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Entity Type | Organization
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Legal Business Name | COVENANT 21ST CENTURY MINISTRIES, INC
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Dates
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Enumeration Date | 03/11/2008
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Last Update Date | 04/14/2009
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Provider Practice Location Address
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Address Line | 260 FILBERT ST
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City | NORFOLK
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State | VA
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Zip | 23505-4410
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Country | US
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Telephone | 757-493-2912
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Fax | 757-493-2913
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Provider Business Mailing Address
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Address Line | 5301 PROVIDENCE RD SUITE 20
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City | VIRGINIA BEACH
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State | VA
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Zip | 23464-4128
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Country | US
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Telephone | 757-493-2912
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Fax | 757-493-2913
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | DR. PORTIA DENEEN RAWLES
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Credential | PSY D
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Telephone | 757-493-2912
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | 80714001
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License Number State | VA
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