Healthcare Provider Details

I. General information

NPI: 1609545003
Provider Name (Legal Business Name): GENESIS TMS & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 07/27/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10337B DEMOCRACY LN
FAIRFAX VA
22030-2521
US

IV. Provider business mailing address

10337 DEMOCRACY LN STE B
FAIRFAX VA
22030-2551
US

V. Phone/Fax

Practice location:
  • Phone: 703-955-0915
  • Fax:
Mailing address:
  • Phone: 703-955-0915
  • Fax: 248-243-8804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. IFEANYI M. OLELE
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 310-213-9945