Provider Demographics
NPI:1619158847
Name:GENESIS FAMILY SUPPORT SERVICES, INC.
Entity Type:Organization
Organization Name:GENESIS FAMILY SUPPORT SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-224-7067
Mailing Address - Street 1:PO BOX 3183
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-3183
Mailing Address - Country:US
Mailing Address - Phone:502-224-7067
Mailing Address - Fax:
Practice Address - Street 1:223 E MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-2025
Practice Address - Country:US
Practice Address - Phone:502-224-7067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY29100054Medicaid