Basic Information
| Provider Information | |||||||||
| NPI: | 1437274263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LALOS | ||||||||
| FirstName: | GENISE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LSW, CAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEFLIN | ||||||||
| OtherFirstName: | GENISE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LSW, CAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2 ROBIN LN | ||||||||
| Address2: | SHERWOOD ESTATES | ||||||||
| City: | ONA | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255459749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047366874 | ||||||||
| FaxNumber: | 3046971286 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257041519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045257851 | ||||||||
| FaxNumber: | 3046971286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 95-302S | WV | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | AP00940219 | WV | X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | AP00940219 | 01 | WV | LSW | OTHER | 95-102S | 01 | WV | CCS | OTHER | 95-302S | 01 | WV | CCAC | OTHER |