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General NPI Number Information
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NPI Number | 1689898272
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Entity Type | Organization
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Legal Business Name | GENESIS COUNSELING GROUP, S.C.
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Dates
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Enumeration Date | 04/13/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 890 ELM GROVE RD SUITE 4
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City | ELM GROVE
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State | WI
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Zip | 53122-2528
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Country | US
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Telephone | 262-780-0991
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Fax | 262-780-0992
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Provider Business Mailing Address
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Address Line | 890 ELM GROVE RD SUITE 4
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City | ELM GROVE
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State | WI
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Zip | 53122-2528
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Country | US
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Telephone | 262-780-0991
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Fax | 262-780-0992
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Authorized Official
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Title or Position | PRESIDENT CLINICAL PSYCHOLOGIST
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Name | DR. GARY R GREGG
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Credential | PSY.D.
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Telephone | 262-780-0991
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2195
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License Number State | WI
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