Provider Demographics
NPI:1235695701
Name:THE GENESIS WELLNESS CENTER PLLC
Entity Type:Organization
Organization Name:THE GENESIS WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LSSP, LPC-S
Authorized Official - Phone:832-429-4917
Mailing Address - Street 1:11757 KATY FWY STE 1300
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-1725
Mailing Address - Country:US
Mailing Address - Phone:832-429-4917
Mailing Address - Fax:
Practice Address - Street 1:11757 KATY FWY STE 1300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-1725
Practice Address - Country:US
Practice Address - Phone:832-429-4917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty