Provider Demographics
NPI:1649869876
Name:GENESIS CLINICAL COUNSELING, LLC
Entity type:Organization
Organization Name:GENESIS CLINICAL COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SORRYE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:904-219-5560
Mailing Address - Street 1:2255 DUNN AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4739
Mailing Address - Country:US
Mailing Address - Phone:904-201-9658
Mailing Address - Fax:
Practice Address - Street 1:2255 DUNN AVE STE 206
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4739
Practice Address - Country:US
Practice Address - Phone:904-201-9658
Practice Address - Fax:866-270-8565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
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