MEDICARE: CHERYL GENIESSE BCBA

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	103K00000X	Behavior Analyst	1-16-23269

General Provider Information

NPI Number	:	1063961274
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERYL GENIESSE BCBA

Provider Business Mailing Address
First Line	:	29691 6 MILE RD # 100D
Second Line	:
City	:	LIVONIA
State	:	MI
Zip	:	48152-8606
Country	:	US
Telephone Number	:	866-727-8274
Fax Number	:

Provider Business Practice Location Address
First Line	:	29691 6 MILE RD # 100D
Second Line	:
City	:	LIVONIA
State	:	MI
Zip	:	48152-8606
Country	:	US
Telephone Number	:	866-727-8274
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2016
Last Update Date	:	05/15/2020

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