Healthcare Provider Details

I. General information

NPI: 1093890261
Provider Name (Legal Business Name): GENESIS BEHAVIORAL HEALTH AND COLLABORATIVE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 PATRICK HENRY PKWY STE 225
MCDONOUGH GA
30253-4214
US

IV. Provider business mailing address

2340 PATRICK HENRY PKWY STE 225
MCDONOUGH GA
30253-4214
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-8100
  • Fax: 770-389-3030
Mailing address:
  • Phone: 770-389-8100
  • Fax: 770-389-3030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number050537
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number050537
License Number StateGA

VIII. Authorized Official

Name: DR. YOLANDA MALONE-GILBERT
Title or Position: PROVIDER
Credential: M.D.
Phone: 770-389-8100