MEDICARE: GENESIS GREY

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	104100000X	Social Worker	BBH-LCSW-LIC-72746	MT
2	104100000X	Social Worker	SC61406356	WA
3	104100000X	Social Worker	CO18321	NC

General Provider Information

NPI Number	:	1215600929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENESIS GREY

Provider Business Mailing Address
First Line	:	1900 27TH AVE
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59804-5136
Country	:	US
Telephone Number	:	619-994-9068
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 27TH AVE
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59804-5152
Country	:	US
Telephone Number	:	619-994-9068
Fax Number	:

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

Provider Enumeration Date	:	07/28/2021
Last Update Date	:	01/23/2026

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Directions to “ GENESIS GREY ” Practice Location

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