Healthcare Provider Details

I. General information

NPI: 1104676014
Provider Name (Legal Business Name): ALEXA LEE GENESI CADC-III
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 E HILLCREST DR STE 110
THOUSAND OAKS CA
91360-4226
US

IV. Provider business mailing address

PO BOX 7741
WESTLAKE VILLAGE CA
91359-7741
US

V. Phone/Fax

Practice location:
  • Phone: 818-390-9444
  • Fax: 818-381-0007
Mailing address:
  • Phone: 818-390-9444
  • Fax: 818-381-0007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: