Provider Demographics
NPI:1104058866
Name:GENESIS REHAB
Entity type:Organization
Organization Name:GENESIS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:CHERYL
Authorized Official - Last Name:BRAVERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:239-282-3814
Mailing Address - Street 1:74 RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-3440
Mailing Address - Country:US
Mailing Address - Phone:239-254-1020
Mailing Address - Fax:239-597-5289
Practice Address - Street 1:2626 GOODLETTE RD N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-4526
Practice Address - Country:US
Practice Address - Phone:239-262-3814
Practice Address - Fax:239-262-5687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6013302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization