Provider Demographics
NPI:1194097733
Name:COVENANT OF LOVE MARRIAGE MINISTRY, LLC
Entity type:Organization
Organization Name:COVENANT OF LOVE MARRIAGE MINISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PASTORAL COUNSELO
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:PAYNE
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:336-855-7912
Mailing Address - Street 1:2514 DENVER DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-6304
Mailing Address - Country:US
Mailing Address - Phone:336-855-7912
Mailing Address - Fax:336-852-9858
Practice Address - Street 1:2514 DENVER DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-6304
Practice Address - Country:US
Practice Address - Phone:336-855-7912
Practice Address - Fax:336-852-9858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-28
Last Update Date:2012-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0997348101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty