Basic Information
| Provider Information | |||||||||
| NPI: | 1447264890 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS THERAPY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6006 W. 159TH STREET, BLDG. C | ||||||||
| Address2: | |||||||||
| City: | OAK FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085357320 | ||||||||
| FaxNumber: | 7085357571 | ||||||||
| Practice Location | |||||||||
| Address1: | 6006 W. 159TH STREET, BLDG. C | ||||||||
| Address2: | |||||||||
| City: | OAK FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085357320 | ||||||||
| FaxNumber: | 7085357571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 09/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | FAIRFIELD | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7085357320 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.MIN., LCPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TB0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC1900X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103TP2701X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.