1053822130 NPI number — MS. GENEVI J AGE LCSWA, LCAS-A

Table of content: MS. GENEVI J AGE LCSWA, LCAS-A (NPI 1053822130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053822130 NPI number — MS. GENEVI J AGE LCSWA, LCAS-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AGE
Provider First Name:
GENEVI
Provider Middle Name:
J
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSWA, LCAS-A
Provider Gender Code:
F

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:
1053822130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1060 PADDINGTON AVE, NORTHEAST
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
LELAND
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-872-6220
Provider Business Mailing Address Fax Number:
919-872-6223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4805 GREEN RD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27616-2848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-872-6220
Provider Business Practice Location Address Fax Number:
919-872-6223
Provider Enumeration Date:
10/17/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  LCAS-23005 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: P021939 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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