Provider Demographics
NPI:1801995832
Name:GENESIS HOUSE INC
Entity type:Organization
Organization Name:GENESIS HOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:DE SANTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-322-0520
Mailing Address - Street 1:800 W FOURTH STREET
Mailing Address - Street 2:SUITE G01
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701
Mailing Address - Country:US
Mailing Address - Phone:570-322-0520
Mailing Address - Fax:570-326-9674
Practice Address - Street 1:800 W FOURTH STREET
Practice Address - Street 2:SUITE G01
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701
Practice Address - Country:US
Practice Address - Phone:570-322-0520
Practice Address - Fax:570-326-9674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA417015101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007283800008Medicaid
PA807234OtherFPH NE PA
PA999036OtherBC NE PA