Provider Demographics
NPI:1558551101
Name:GENESIS PSYCHOLOGICAL SERVICES, LCC
Entity Type:Organization
Organization Name:GENESIS PSYCHOLOGICAL SERVICES, LCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-287-7989
Mailing Address - Street 1:723 MOUNT MORIAH RD
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-9371
Mailing Address - Country:US
Mailing Address - Phone:252-287-7989
Mailing Address - Fax:
Practice Address - Street 1:723 MOUNT MORIAH RD
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-9371
Practice Address - Country:US
Practice Address - Phone:252-287-7989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2147103T00000X, 103TC0700X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty