Healthcare Provider Details

I. General information

NPI: 1225688906
Provider Name (Legal Business Name): THE GENESIS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 11/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

457 GRISWOLD RD
ELYRIA OH
44035-2304
US

IV. Provider business mailing address

457 GRISWOLD RD
ELYRIA OH
44035-2304
US

V. Phone/Fax

Practice location:
  • Phone: 440-406-8006
  • Fax: 440-406-8097
Mailing address:
  • Phone: 440-406-8006
  • Fax: 440-406-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: LISA MARIE HOLLO
Title or Position: DIRECTOR
Credential: MA ATR LPCC-S
Phone: 440-406-8006