MEDICARE: GENESIS YOUTH CRISIS CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	13GR20	WV

General Provider Information

NPI Number	:	1033585542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENESIS YOUTH CRISIS CENTER INC

Provider Business Mailing Address
First Line	:	PO BOX 546
Second Line	:
City	:	CLARKSBURG
State	:	WV
Zip	:	26302-0546
Country	:	US
Telephone Number	:	304-622-1907
Fax Number	:	304-623-9346

Provider Business Practice Location Address
First Line	:	192 SAFE HAVEN DR
Second Line	:
City	:	CLARKSBURG
State	:	WV
Zip	:	26301-9103
Country	:	US
Telephone Number	:	304-622-1907
Fax Number	:	304-623-9346

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MATT RUDDER
Credential	:	MBA
Telephone Number	:	304-622-1907

Provider Enumeration Date	:	08/19/2015
Last Update Date	:	08/19/2015

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