Provider Demographics
NPI:1255454120
Name:GENOA SERVICES LLC
Entity type:Organization
Organization Name:GENOA SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SINGLE MEMBER
Authorized Official - Prefix:MISS
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:D
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:219-808-0793
Mailing Address - Street 1:222 INDIANAPOLIS BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-1275
Mailing Address - Country:US
Mailing Address - Phone:219-808-0793
Mailing Address - Fax:219-756-0795
Practice Address - Street 1:222 INDIANAPOLIS BLVD STE 207
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-1275
Practice Address - Country:US
Practice Address - Phone:219-808-0793
Practice Address - Fax:219-756-0795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-07
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99025162A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100475220CMedicaid
IN200240460AMedicaid
IN229790Medicare PIN
IN263270Medicare PIN
IN100475220CMedicaid
IN200240460AMedicaid