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General NPI Number Information
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NPI Number | 1689909582
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Entity Type | Organization
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Legal Business Name | GENESIS BEHAVIOR CENTER, INC
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Dates
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Enumeration Date | 10/09/2009
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Last Update Date | 10/09/2009
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Provider Practice Location Address
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Address Line | 528 14TH GENESIS BEHAVIOR CENTER, INC.
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City | MODESTO
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State | CA
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Zip | 95354
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Country | US
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Telephone | 209-577-2014
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Fax | 209-577-1718
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Provider Business Mailing Address
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Address Line | 528 14TH GENESIS BEHAVIOR CENTER, INC.
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City | MODESTO
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State | CA
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Zip | 95354
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Country | US
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Telephone | 209-577-2014
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Fax | 209-577-1718
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Authorized Official
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Title or Position | BEHAVIOR ANALYST
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Name | MRS. ROMINA KIRYAKOUS
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Credential | M.A.(PH.D,INPROGRESS
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Telephone | 209-495-7724
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 103TF0000X
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Taxonomy Name | Family Psychologist
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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