Basic Information
| Provider Information | |||||||||
| NPI: | 1033682802 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS SPECIALTY GROUPS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 83581 | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257719980 | ||||||||
| FaxNumber: | 2256126420 | ||||||||
| Practice Location | |||||||||
| Address1: | 778 CHEVELLE DRIVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257718890 | ||||||||
| FaxNumber: | 2256126920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2019 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | STUART | ||||||||
| AuthorizedOfficialFirstName: | TANYA | ||||||||
| AuthorizedOfficialMiddleName: | MEKDESSIE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2257719980 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.