Provider Demographics
| NPI: | 1841866068 |
|---|---|
| Name: | GENESIS PROJECT FAMILY WELLNESS CENTER, INC. |
| Entity type: | Organization |
| Organization Name: | GENESIS PROJECT FAMILY WELLNESS CENTER, INC. |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | TRASHA |
| Authorized Official - Middle Name: | J |
| Authorized Official - Last Name: | BLACK |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | PHD LCMHC |
| Authorized Official - Phone: | 704-596-0505 |
| Mailing Address - Street 1: | 5104 REAGAN DR STE 5 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | CHARLOTTE |
| Mailing Address - State: | NC |
| Mailing Address - Zip Code: | 28206-1392 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 704-596-0505 |
| Mailing Address - Fax: | 704-596-0507 |
| Practice Address - Street 1: | 5104 REAGAN DR STE 5 |
| Practice Address - Street 2: | |
| Practice Address - City: | CHARLOTTE |
| Practice Address - State: | NC |
| Practice Address - Zip Code: | 28206-1392 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 704-596-0505 |
| Practice Address - Fax: | 704-596-0507 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2021-05-28 |
| Last Update Date: | 2021-05-28 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QC1500X | Ambulatory Health Care Facilities | Clinic/Center | Community Health | |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 251B00000X | Agencies | Case Management | ||
| No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | ||
| No | 251S00000X | Agencies | Community/Behavioral Health | ||
| No | 251V00000X | Agencies | Voluntary or Charitable | ||
| No | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center | ||
| No | 261QF0050X | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical | |
| No | 261QH0100X | Ambulatory Health Care Facilities | Clinic/Center | Health Service | |
| No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
| No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | |
| No | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | |
| No | 261QR0401X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) | |
| No | 261QR1300X | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | |
| No | 261QU0200X | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
