Provider Demographics
NPI:1730234204
Name:COVENANT COUNSELING CENTER, INC.
Entity type:Organization
Organization Name:COVENANT COUNSELING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:K
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:2007-01-24
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002049103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty