=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497430060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS OUTPATIENT SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2023
-----------------------------------------------------
Last Update Date | 12/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9200 FOREST HILL AVE STE C2
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-6867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-447-9030
-----------------------------------------------------
Fax | 804-658-0033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9200 FOREST HILL AVE STE C2
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-6867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-447-9030
-----------------------------------------------------
Fax | 804-658-0033
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIELL TWYMAN
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 804-721-8616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------