Healthcare Provider Details

I. General information

NPI: 1457760118
Provider Name (Legal Business Name): GENESIS COUNSELING CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 TAYLOR RD
CHESAPEAKE VA
23321-2207
US

IV. Provider business mailing address

2202 EXECUTIVE DR SUITE C
HAMPTON VA
23666-6604
US

V. Phone/Fax

Practice location:
  • Phone: 757-827-7707
  • Fax: 757-838-2573
Mailing address:
  • Phone: 757-827-7707
  • Fax: 757-838-2573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904002090
License Number StateVA

VIII. Authorized Official

Name: CAMERON ASHWORTH
Title or Position: VP OF OPERATIONS
Credential:
Phone: 757-827-7707