Provider Demographics
NPI:1831264118
Name:GENESIS BEHAVIORAL HEALTH CARE SERVICES, INC.
Entity type:Organization
Organization Name:GENESIS BEHAVIORAL HEALTH CARE SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:706-636-5679
Mailing Address - Street 1:34 OAK ST
Mailing Address - Street 2:P O BOX 1659
Mailing Address - City:EAST ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-8151
Mailing Address - Country:US
Mailing Address - Phone:706-636-5679
Mailing Address - Fax:706-636-5680
Practice Address - Street 1:34 OAK ST
Practice Address - Street 2:
Practice Address - City:EAST ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-8151
Practice Address - Country:US
Practice Address - Phone:706-636-5679
Practice Address - Fax:706-636-5680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1824251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00626315EMedicaid
GAS34160Medicare UPIN
GA00626315EMedicaid