Provider Demographics
NPI:1043588254
Name:GENESIS BEHAVIORAL SERVICES, INC
Entity Type:Organization
Organization Name:GENESIS BEHAVIORAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KUNZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA,LPC,NCC,CSAC,ICS
Authorized Official - Phone:262-338-8611
Mailing Address - Street 1:1626 CLARENCE CT
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-8533
Mailing Address - Country:US
Mailing Address - Phone:262-338-8611
Mailing Address - Fax:262-338-3367
Practice Address - Street 1:1626 CLARENCE CT
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-8533
Practice Address - Country:US
Practice Address - Phone:262-338-8611
Practice Address - Fax:262-338-3367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16431 - 130101YA0400X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1568620466Medicaid