MEDICARE: THE GENESIS WELLNESS CENTER PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
4	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1235695701
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE GENESIS WELLNESS CENTER PLLC

Provider Business Mailing Address
First Line	:	23144 CINCO RANCH BLVD STE B
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-2893
Country	:	US
Telephone Number	:	832-429-4917
Fax Number	:

Provider Business Practice Location Address
First Line	:	11757 KATY FWY STE 1300
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77079-1725
Country	:	US
Telephone Number	:	832-429-4917
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST/OWNER
Name	:	DR. MARY MCCULLOUGH
Credential	:	PHD, LSSP, LPC-S
Telephone Number	:	832-429-4917

Provider Enumeration Date	:	02/20/2019
Last Update Date	:	11/05/2024

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