Provider Demographics
NPI:1245789940
Name:GENESIS PSYCHOLOGY GROUP, INC.
Entity Type:Organization
Organization Name:GENESIS PSYCHOLOGY GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOEHM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:310-837-2444
Mailing Address - Street 1:3611 MOTOR AVE.
Mailing Address - Street 2:SUITE 240
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034
Mailing Address - Country:US
Mailing Address - Phone:310-837-2444
Mailing Address - Fax:
Practice Address - Street 1:3611 MOTOR AVE.
Practice Address - Street 2:SUITE 240
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034
Practice Address - Country:US
Practice Address - Phone:310-837-2444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC2894551103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty