=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184323636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS- PREVENT PROTECT PROVIDE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2023
-----------------------------------------------------
Last Update Date | 02/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 379 CHALICE RD.
-----------------------------------------------------
City | WESTCLIFFE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-371-2472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 744
-----------------------------------------------------
City | WESTCLIFFE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81252-0744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-371-2472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | FAWNDA NEWTON
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 719-371-2472
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------