=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598117822
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENERATIONS COMMUNITY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2016
-----------------------------------------------------
Last Update Date | 07/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 217 N MADISON ST SUITE 5
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54301-5103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-228-3199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 217 N MADISON ST SUITE 5
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54301-5103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-228-3199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR/CEO
-----------------------------------------------------
Name | LESLIE CARROLL OUSLEY
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 920-228-3199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------