Provider Demographics
NPI:1811024375
Name:GENESIS PARTIAL HOSPITALIZATION
Entity Type:Organization
Organization Name:GENESIS PARTIAL HOSPITALIZATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLYNISS
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-748-5280
Mailing Address - Street 1:10270 HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:AMITE
Mailing Address - State:LA
Mailing Address - Zip Code:70422-4170
Mailing Address - Country:US
Mailing Address - Phone:985-748-5280
Mailing Address - Fax:985-748-5152
Practice Address - Street 1:10270 HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:AMITE
Practice Address - State:LA
Practice Address - Zip Code:70422-4170
Practice Address - Country:US
Practice Address - Phone:985-748-5280
Practice Address - Fax:985-748-5152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA194668Medicare ID - Type UnspecifiedCMHC