Healthcare Provider Details

I. General information

NPI: 1689898272
Provider Name (Legal Business Name): GENESIS COUNSELING GROUP, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 ELM GROVE RD SUITE 4
ELM GROVE WI
53122-2528
US

IV. Provider business mailing address

890 ELM GROVE RD SUITE 4
ELM GROVE WI
53122-2528
US

V. Phone/Fax

Practice location:
  • Phone: 262-780-0991
  • Fax: 262-780-0992
Mailing address:
  • Phone: 262-780-0991
  • Fax: 262-780-0992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2195
License Number StateWI

VIII. Authorized Official

Name: DR. GARY R GREGG
Title or Position: PRESIDENT CLINICAL PSYCHOLOGIST
Credential: PSY.D.
Phone: 262-780-0991