Healthcare Provider Details

I. General information

NPI: 1326187469
Provider Name (Legal Business Name): GENESIS PROJECT 1, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/27/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5104 REAGAN DR STE 5
CHARLOTTE NC
28206-1392
US

IV. Provider business mailing address

PO BOX 560723
CHARLOTTE NC
28256-0723
US

V. Phone/Fax

Practice location:
  • Phone: 704-596-0505
  • Fax:
Mailing address:
  • Phone: 704-596-0505
  • Fax: 704-596-0507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. SYLVIA L. GRIER
Title or Position: MANAGER
Credential: MSO
Phone: 704-596-0505