Provider Demographics
NPI:1669211082
Name:YOUR GENX THERAPIST LLC
Entity type:Organization
Organization Name:YOUR GENX THERAPIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:818-208-4774
Mailing Address - Street 1:4348 E PIC A DILLY DR
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-9681
Mailing Address - Country:US
Mailing Address - Phone:818-468-8276
Mailing Address - Fax:
Practice Address - Street 1:4539 WOODGATE DR STE A8
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-8205
Practice Address - Country:US
Practice Address - Phone:818-208-4774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-23
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty