=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497208524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2016
-----------------------------------------------------
Last Update Date | 07/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 N DIXIE AVE STE 2
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42701-2764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-991-2951
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 N DIXIE AVE STE 2
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42701-2764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-991-2951
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. CHARLOTTE C. DAVIS
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 270-991-2951
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 161534
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------