MEDICARE: COVENANT YOUTH & FAMILY SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)		OK

General Provider Information

NPI Number	:	1760508006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COVENANT YOUTH & FAMILY SERVICES

Provider Business Mailing Address
First Line	:	3813 N SANTA FE AVE
Second Line	:	SUITE 131
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-8508
Country	:	US
Telephone Number	:	405-521-1755
Fax Number	:	405-521-1138

Provider Business Practice Location Address
First Line	:	3813 N SANTA FE AVE
Second Line	:	SUITE 131
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-8508
Country	:	US
Telephone Number	:	405-521-1755
Fax Number	:	405-521-1138

Authorized Official
Title or Position	:	CEO
Name	:	MRS. ROSELINE NSIKAK
Credential	:
Telephone Number	:	405-623-1117

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	08/22/2020

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