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General NPI Number Information
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NPI Number | 1780394031
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Entity Type | Organization
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Legal Business Name | MY COVENANT PLACE BEHAVIORAL HEALTH
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Dates
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Enumeration Date | 11/28/2022
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Last Update Date | 12/16/2022
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Provider Practice Location Address
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Address Line | 5109 YORK ROAD SUITE C- 2ND FLOOR
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City | BALTIMORE
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State | MD
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Zip | 21212-2121
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Country | US
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Telephone | 443-759-3355
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Fax |
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Provider Business Mailing Address
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Address Line | 5109 YORK RD SUITE C, 2ND FLOOR
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City | BALTIMORE
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State | MD
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Zip | 21212-4399
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Country | US
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Telephone | 443-759-3355
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Fax | 443-990-0009
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | LATISHA CARTER
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Credential |
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Telephone | 410-660-9190
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State |
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