Provider Demographics
NPI:1912619818
Name:GENESIS INNOVATIVE SOLUTIONS
Entity type:Organization
Organization Name:GENESIS INNOVATIVE SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAKARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-565-3796
Mailing Address - Street 1:323 CLIFTON ST STE 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5053
Mailing Address - Country:US
Mailing Address - Phone:252-565-3796
Mailing Address - Fax:
Practice Address - Street 1:323 CLIFTON ST STE 4
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5053
Practice Address - Country:US
Practice Address - Phone:252-565-3796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-22
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty