Provider Demographics
NPI:1871811547
Name:COVENANT YOUTH AND FAMILY SERVICES
Entity type:Organization
Organization Name:COVENANT YOUTH AND FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTIVER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:POULTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-521-1755
Mailing Address - Street 1:3005 NW 63RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-3603
Mailing Address - Country:US
Mailing Address - Phone:405-521-1755
Mailing Address - Fax:405-521-1138
Practice Address - Street 1:2408 PANTHEON CIR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-3236
Practice Address - Country:US
Practice Address - Phone:405-226-9593
Practice Address - Fax:405-521-1138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health