Basic Information
| Provider Information | |||||||||
| NPI: | 1891020137 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE GENESIS THERAPY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6006 159TH ST | ||||||||
| Address2: | |||||||||
| City: | OAK FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604522904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085357320 | ||||||||
| FaxNumber: | 7085357571 | ||||||||
| Practice Location | |||||||||
| Address1: | 6006 WEST 159TH STREET | ||||||||
| Address2: | |||||||||
| City: | OAK FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604522904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085357320 | ||||||||
| FaxNumber: | 7085357571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2009 | ||||||||
| LastUpdateDate: | 10/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | FAIRFIELD | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7085357320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 178.005630 | IL | Y | Agencies | Community/Behavioral Health |
No ID Information.