Provider Demographics
NPI:1467627992
Name:GENESIS BEHAVIORAL SERVICES, INC
Entity Type:Organization
Organization Name:GENESIS BEHAVIORAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUBTANCE ABUSE COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ARTURO
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:LEO
Authorized Official - Suffix:
Authorized Official - Credentials:BSW, CSAC
Authorized Official - Phone:262-633-5001
Mailing Address - Street 1:1654 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-2047
Mailing Address - Country:US
Mailing Address - Phone:262-633-5001
Mailing Address - Fax:262-633-2928
Practice Address - Street 1:1654 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2047
Practice Address - Country:US
Practice Address - Phone:262-633-5001
Practice Address - Fax:262-633-2928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10570251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10570OtherLICENSE NUMBER
WI39389900Medicaid