Healthcare Provider Details

I. General information

NPI: 1043588254
Provider Name (Legal Business Name): GENESIS BEHAVIORAL SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 CLARENCE CT
WEST BEND WI
53095-8533
US

IV. Provider business mailing address

1626 CLARENCE CT
WEST BEND WI
53095-8533
US

V. Phone/Fax

Practice location:
  • Phone: 262-338-8611
  • Fax: 262-338-3367
Mailing address:
  • Phone: 262-338-8611
  • Fax: 262-338-3367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16431 - 130
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number16431 - 130
License Number StateWI

VIII. Authorized Official

Name: MS. KIMBERLY A KUNZ
Title or Position: DIRECTOR
Credential: MA,LPC,NCC,CSAC,ICS
Phone: 262-338-8611