Provider Demographics
NPI:1851161467
Name:GENESIS THERAPEUTIC SERVICES, LLC
Entity Type:Organization
Organization Name:GENESIS THERAPEUTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-472-1433
Mailing Address - Street 1:2139 PRINCESS ANNE CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1456
Mailing Address - Country:US
Mailing Address - Phone:240-472-1433
Mailing Address - Fax:
Practice Address - Street 1:7157 MAHOGANY DR
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-5818
Practice Address - Country:US
Practice Address - Phone:240-472-1433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health