Healthcare Provider Details

I. General information

NPI: 1821206715
Provider Name (Legal Business Name): GENESIS YOUTH CRISIS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 HORNER AVE
CLARKSBURG WV
26301-3616
US

IV. Provider business mailing address

535 HORNER AVE
CLARKSBURG WV
26301-3616
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 Number
License Number State

VIII. Authorized Official

Name: MR. MATT RUDDER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 304-622-1907