Healthcare Provider Details

I. General information

NPI: 1235695701
Provider Name (Legal Business Name): THE GENESIS WELLNESS CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11757 KATY FWY STE 1300
HOUSTON TX
77079-1725
US

IV. Provider business mailing address

23144 CINCO RANCH BLVD STE B
KATY TX
77494-2893
US

V. Phone/Fax

Practice location:
  • Phone: 832-429-4917
  • Fax:
Mailing address:
  • Phone: 832-429-4917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. MARY MCCULLOUGH
Title or Position: THERAPIST/OWNER
Credential: PHD, LSSP, LPC-S
Phone: 832-429-4917