Provider Demographics
NPI:1821206715
Name:GENESIS YOUTH CRISIS CENTER
Entity Type:Organization
Organization Name:GENESIS YOUTH CRISIS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-622-1907
Mailing Address - Street 1:535 HORNER AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-3616
Mailing Address - Country:US
Mailing Address - Phone:304-622-1907
Mailing Address - Fax:304-623-9346
Practice Address - Street 1:535 HORNER AVE
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-3616
Practice Address - Country:US
Practice Address - Phone:304-622-1907
Practice Address - Fax:304-623-9346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0158712001Medicaid