Provider Demographics
NPI:1962179085
Name:DURAN, GENESIS MARIE
Entity type:Individual
Prefix:
First Name:GENESIS
Middle Name:MARIE
Last Name:DURAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12501 SUNNY VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-9441
Mailing Address - Country:US
Mailing Address - Phone:559-310-1562
Mailing Address - Fax:
Practice Address - Street 1:12501 SUNNY VISTA AVE
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-9441
Practice Address - Country:US
Practice Address - Phone:559-310-1562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician