=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861836272
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENESIS CMHC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2013
-----------------------------------------------------
Last Update Date | 06/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20251 SATICOY STREET.
-----------------------------------------------------
City | WINNETKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91306-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-349-4220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20251 SATICOY ST
-----------------------------------------------------
City | WINNETKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91306-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-349-4220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. STELLA SHAHANGIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-349-4220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------