Provider Demographics
NPI:1417364480
Name:GENESIS PROJECT 1
Entity Type:Organization
Organization Name:GENESIS PROJECT 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TRASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-596-0505
Mailing Address - Street 1:5108 REAGAN DR
Mailing Address - Street 2:SUITE 14
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-3103
Mailing Address - Country:US
Mailing Address - Phone:704-596-0505
Mailing Address - Fax:704-596-0507
Practice Address - Street 1:5108 REAGAN DR
Practice Address - Street 2:SUITE 14
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-3103
Practice Address - Country:US
Practice Address - Phone:704-596-0505
Practice Address - Fax:704-596-0507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP009049305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service