Provider Demographics
NPI:1033585542
Name:GENESIS YOUTH CRISIS CENTER INC
Entity Type:Organization
Organization Name:GENESIS YOUTH CRISIS CENTER INC
Other - Org Name:GENESIS FAMILY DEVELOPMENT SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDDER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:304-622-1907
Mailing Address - Street 1:PO BOX 546
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26302-0546
Mailing Address - Country:US
Mailing Address - Phone:304-622-1907
Mailing Address - Fax:304-623-9346
Practice Address - Street 1:192 SAFE HAVEN DR
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-9103
Practice Address - Country:US
Practice Address - Phone:304-622-1907
Practice Address - Fax:304-623-9346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13GR20251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health