Basic Information
Provider Information | |||||||||
NPI: | 1073741914 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GENESIS REHAB SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 CIVIC AVENUE | ||||||||
Address2: | GENESIS REHAB SERVICES | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 21804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4107491466 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 200 CIVIC AVENUE | ||||||||
Address2: | GENESIS REHAB SERVICES | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 21804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4107491466 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2009 | ||||||||
LastUpdateDate: | 06/30/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ASHLEY | ||||||||
AuthorizedOfficialFirstName: | TRACIE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | SPEECH LANGUAGE PATHOLOGIST | ||||||||
AuthorizedOfficialTelephone: | 4107491466 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.S.,CCC-SLP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 05510 | MD | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.