1801088604 NPI number — GENESIS COUNSELING CENTER, INC.

Table of content: (NPI 1801088604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801088604 NPI number — GENESIS COUNSELING CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENESIS COUNSELING CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801088604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 901402
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44190-1402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17747 CHILLICOTHE RD
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
CHAGRIN FALLS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44023-4739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-543-8880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FIKTER
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
440-543-8880

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  35.063299 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000136790 . This is a "ANTHEM BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 191762 . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0147004 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5781747 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".