=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831264118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS BEHAVIORAL HEALTH CARE SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34 OAK ST
-----------------------------------------------------
City | EAST ELLIJAY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30540-8151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-636-5679
-----------------------------------------------------
Fax | 706-636-5680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34 OAK ST P O BOX 1659
-----------------------------------------------------
City | EAST ELLIJAY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30540-8151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-636-5679
-----------------------------------------------------
Fax | 706-636-5680
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHAIRMAN CEO
-----------------------------------------------------
Name | DR. GARY L ROGERS
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 706-636-5679
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 1824
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------