Healthcare Provider Details

I. General information

NPI: 1255081675
Provider Name (Legal Business Name): GENESIS YOUTH CRISIS CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 03/28/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 PRESSLEY RIDGE RD
CLARKSBURG WV
26301-7024
US

IV. Provider business mailing address

192 SAFE HAVEN DR
CLARKSBURG WV
26301-9103
US

V. Phone/Fax

Practice location:
  • Phone: 304-709-7020
  • Fax: 681-399-9115
Mailing address:
  • Phone: 304-622-1907
  • Fax: 304-623-9346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT MAYER
Title or Position: CQI SPECIALIST
Credential: BA, LSW
Phone: 304-622-1907