Provider Demographics
| NPI: | 1306236179 |
|---|---|
| Name: | GENESIS P.A.C.E.S. LLP |
| Entity type: | Organization |
| Organization Name: | GENESIS P.A.C.E.S. LLP |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CO-OWNER |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | CLEDICIANNE |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | DORVIL |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | PSYD |
| Authorized Official - Phone: | 609-393-1166 |
| Mailing Address - Street 1: | 826 W STATE ST |
| Mailing Address - Street 2: | SUITE A. |
| Mailing Address - City: | TRENTON |
| Mailing Address - State: | NJ |
| Mailing Address - Zip Code: | 08618-5350 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 609-393-1166 |
| Mailing Address - Fax: | 609-393-2140 |
| Practice Address - Street 1: | 826 W STATE ST |
| Practice Address - Street 2: | SUITE A. |
| Practice Address - City: | TRENTON |
| Practice Address - State: | NJ |
| Practice Address - Zip Code: | 08618-5350 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 609-393-1166 |
| Practice Address - Fax: | 609-393-2140 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2015-01-30 |
| Last Update Date: | 2015-05-06 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 101Y00000X, 101YA0400X, 101YM0800X, 103G00000X, 103T00000X, 103TB0200X, 103TF0000X, 103TF0200X, 103TM1800X, 103TP2701X, 103TS0200X, 106H00000X, 103TC2200X | ||
| NJ | 103TC1900X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
| No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 103G00000X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | Group - Multi-Specialty | |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
| No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |
| No | 103TF0000X | Behavioral Health & Social Service Providers | Psychologist | Family | Group - Multi-Specialty |
| No | 103TF0200X | Behavioral Health & Social Service Providers | Psychologist | Forensic | Group - Multi-Specialty |
| No | 103TM1800X | Behavioral Health & Social Service Providers | Psychologist | Intellectual & Developmental Disabilities | Group - Multi-Specialty |
| No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Multi-Specialty |
| No | 103TS0200X | Behavioral Health & Social Service Providers | Psychologist | School | Group - Multi-Specialty |
| No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty |
