Healthcare Provider Details

I. General information

NPI: 1760358303
Provider Name (Legal Business Name): GENESIS ADULT EDUCATION ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 10/13/2025
Certification Date: 10/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 S CENTRAL AVE UNIT 982
BARTOW FL
33831-7041
US

IV. Provider business mailing address

220 S CENTRAL AVE UNIT 982
BARTOW FL
33831-7041
US

V. Phone/Fax

Practice location:
  • Phone: 863-934-4375
  • Fax: 863-934-4375
Mailing address:
  • Phone: 863-934-4375
  • Fax: 863-934-4375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: AMBER VELORA SCREEN
Title or Position: OWNER
Credential: LMHC
Phone: 863-934-4375