Provider Demographics
NPI:1215175864
Name:COVENANT COUNSELING CENTER
Entity type:Organization
Organization Name:COVENANT COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:CERJAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:229-890-2288
Mailing Address - Street 1:600 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-5514
Mailing Address - Country:US
Mailing Address - Phone:229-890-2288
Mailing Address - Fax:229-890-2289
Practice Address - Street 1:600 2ND ST SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-5514
Practice Address - Country:US
Practice Address - Phone:229-890-2288
Practice Address - Fax:229-890-2289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW004628104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty