Provider Demographics
NPI:1417134123
Name:GENESIS COUNSELING SERVICE
Entity Type:Organization
Organization Name:GENESIS COUNSELING SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SATELITE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:KNEPP
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:760-375-6348
Mailing Address - Street 1:202 E AIRPORT DR
Mailing Address - Street 2:SUITE #175
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3444
Mailing Address - Country:US
Mailing Address - Phone:909-890-2299
Mailing Address - Fax:
Practice Address - Street 1:1201 N CHINA LAKE BLVD
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-2660
Practice Address - Country:US
Practice Address - Phone:760-375-6348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT24526106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ66427ZOtherBLUE SHIELD CA