Healthcare Provider Details

I. General information

NPI: 1033585542
Provider Name (Legal Business Name): GENESIS YOUTH CRISIS CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 SAFE HAVEN DR
CLARKSBURG WV
26301-9103
US

IV. Provider business mailing address

PO BOX 546
CLARKSBURG WV
26302-0546
US

V. Phone/Fax

Practice location:
  • Phone: 304-622-1907
  • Fax: 304-623-9346
Mailing address:
  • Phone: 304-622-1907
  • Fax: 304-623-9346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number13GR20
License Number StateWV

VIII. Authorized Official

Name: MATT RUDDER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MBA
Phone: 304-622-1907