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General NPI Number Information
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NPI Number | 1528255767
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Entity Type | Organization
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Legal Business Name | FIRST GENESIS GROUP HOME (DBA) BISBEE PLACE
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Dates
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Enumeration Date | 10/02/2007
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Last Update Date | 10/03/2011
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Provider Practice Location Address
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Address Line | 4821 BISBEE DR
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City | GREENSBORO
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State | NC
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Zip | 27407-9710
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Country | US
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Telephone | 336-292-1555
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Fax | 336-274-6608
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Provider Business Mailing Address
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Address Line | 4309 PENTON PLACE
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City | GREENSBORO
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State | NC
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Zip | 27455-1920
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Country | US
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Telephone | 336-292-1555
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Fax | 336-274-6608
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. JANICE M CHAMBERS
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Credential | LPC
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Telephone | 336-292-1555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4173
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701003386
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 041837
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License Number State | NC
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