Provider Demographics
NPI:1265043962
Name:GENESIS BEHAVIORAL HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:GENESIS BEHAVIORAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:769-524-4578
Mailing Address - Street 1:PO BOX 1956
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-1956
Mailing Address - Country:US
Mailing Address - Phone:769-524-4578
Mailing Address - Fax:769-524-4630
Practice Address - Street 1:357 TOWNE CENTER PL STE 200
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4837
Practice Address - Country:US
Practice Address - Phone:769-524-4578
Practice Address - Fax:769-524-4630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty