Provider Demographics
NPI:1679114169
Name:GENESEE VALLEY PSYCHOLOGY, PLLC
Entity Type:Organization
Organization Name:GENESEE VALLEY PSYCHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER OF GENESSE VALLEY PS
Authorized Official - Prefix:DR
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WADSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:585-270-1679
Mailing Address - Street 1:200 WHITE SPRUCE BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623
Mailing Address - Country:US
Mailing Address - Phone:585-201-8017
Mailing Address - Fax:585-495-2384
Practice Address - Street 1:200 WHITE SPRUCE BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623
Practice Address - Country:US
Practice Address - Phone:585-201-8017
Practice Address - Fax:585-495-2384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06508112Medicaid