Provider Demographics
NPI:1215247333
Name:GENESIS REHABILITATION SERVICES
Entity type:Organization
Organization Name:GENESIS REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:MARDJETKO
Authorized Official - Suffix:
Authorized Official - Credentials:MSCCCSLP
Authorized Official - Phone:727-378-8586
Mailing Address - Street 1:7927 STATE ROAD 52
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-6783
Mailing Address - Country:US
Mailing Address - Phone:727-378-8586
Mailing Address - Fax:727-378-8587
Practice Address - Street 1:7927 STATE ROAD 52
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-6783
Practice Address - Country:US
Practice Address - Phone:727-378-8586
Practice Address - Fax:727-378-8587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2502235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty