Provider Demographics
NPI:1659764686
Name:GENYSIS RESTORATION
Entity Type:Organization
Organization Name:GENYSIS RESTORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDLEBROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:DEGREE
Authorized Official - Phone:216-299-8789
Mailing Address - Street 1:324 EUCLID SQUARE MALL
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-2808
Mailing Address - Country:US
Mailing Address - Phone:216-299-8789
Mailing Address - Fax:
Practice Address - Street 1:324 EUCLID SQUARE MALL
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44132-2808
Practice Address - Country:US
Practice Address - Phone:216-299-8789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0000000101YA0400X, 101YP1600X, 101YS0200X, 103TA0400X
OHOH1037248101YM0800X
OH000000103TM1800X, 103TP2701X, 103TR0400X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000000000Medicaid