Provider Demographics
NPI:1689909582
Name:GENESIS BEHAVIOR CENTER, INC
Entity Type:Organization
Organization Name:GENESIS BEHAVIOR CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROMINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRYAKOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MA(PHD,INPROGRESS
Authorized Official - Phone:209-495-7724
Mailing Address - Street 1:528 14TH GENESIS BEHAVIOR CENTER, INC.
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354
Mailing Address - Country:US
Mailing Address - Phone:209-577-2014
Mailing Address - Fax:209-577-1718
Practice Address - Street 1:528 14TH GENESIS BEHAVIOR CENTER, INC.
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354
Practice Address - Country:US
Practice Address - Phone:209-577-2014
Practice Address - Fax:209-577-1718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty