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General NPI Number Information
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NPI Number | 1558551101
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Entity Type | Organization
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Legal Business Name | GENESIS PSYCHOLOGICAL SERVICES, LCC
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Dates
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Enumeration Date | 07/30/2007
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Last Update Date | 07/30/2007
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Provider Practice Location Address
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Address Line | 723 MOUNT MORIAH RD
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City | AHOSKIE
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State | NC
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Zip | 27910-9371
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Country | US
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Telephone | 252-287-7989
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Fax |
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Provider Business Mailing Address
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Address Line | 723 MOUNT MORIAH RD
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City | AHOSKIE
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State | NC
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Zip | 27910-9371
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Country | US
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Telephone | 252-287-7989
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | MRS. MONIQUE E. MITCHELL
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Credential |
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Telephone | 252-287-7989
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 2147
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2147
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 2147
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License Number State | NC
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