Basic Information
| Provider Information | |||||||||
| NPI: | 1346220340 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESIS HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PSYCHOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 865 LINCOLN RD | ||||||||
| Address2: | STE L10 | ||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527224190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559191 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 4455 E 56TH ST | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528072995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633552577 | ||||||||
| FaxNumber: | 5633554015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 11/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | KLEINSCHMIDT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5634216513 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | IA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | IA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103T00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 104100000X | IA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 104100000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 106H00000X | IA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 103T00000X | IA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.