Healthcare Provider Details

I. General information

NPI: 1306004999
Provider Name (Legal Business Name): GENESIS BEHAVIORAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 CLARENCE COURT
WEST BEND WI
53095
US

IV. Provider business mailing address

12647 OLIVE BLVD ATTN: ACCTS. RECEIVEABLE
SAINT LOUIS MO
63141-6393
US

V. Phone/Fax

Practice location:
  • Phone: 262-338-8611
  • Fax: 262-338-3367
Mailing address:
  • Phone: 414-777-1570
  • Fax: 414-777-1565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1465
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1465
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1465
License Number StateWI

VIII. Authorized Official

Name: PAULINE ORTLOFF
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 414-777-1570