Provider Demographics
NPI:1366782690
Name:CHRISTIAN COVENANT COUNSELING SERVICES LLC
Entity type:Organization
Organization Name:CHRISTIAN COVENANT COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:D
Authorized Official - Last Name:HUMPHRIES
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:313-806-6711
Mailing Address - Street 1:5115 GRAYTON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2147
Mailing Address - Country:US
Mailing Address - Phone:313-806-6711
Mailing Address - Fax:313-885-5059
Practice Address - Street 1:5115 GRAYTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-2147
Practice Address - Country:US
Practice Address - Phone:313-806-6711
Practice Address - Fax:313-885-5059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-23
Last Update Date:2013-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty