Provider Demographics
NPI:1306004999
Name:GENESIS BEHAVIORAL SERVICES, INC.
Entity Type:Organization
Organization Name:GENESIS BEHAVIORAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTLOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-777-1570
Mailing Address - Street 1:12647 OLIVE BLVD
Mailing Address - Street 2:ATTN: ACCTS. RECEIVEABLE
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6393
Mailing Address - Country:US
Mailing Address - Phone:414-777-1570
Mailing Address - Fax:414-777-1565
Practice Address - Street 1:1626 CLARENCE COURT
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095
Practice Address - Country:US
Practice Address - Phone:262-338-8611
Practice Address - Fax:262-338-3367
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORIZON HEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-30
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1465101YA0400X, 101YM0800X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42185921Medicaid
WI42185900Medicaid
WI42242221Medicaid
WI42186000Medicaid