Provider Demographics
NPI:1144311853
Name:GENESIS...A NEW BEGINNING
Entity type:Organization
Organization Name:GENESIS...A NEW BEGINNING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:B
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-720-7770
Mailing Address - Street 1:245 LE PHILLIP CT NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2900
Mailing Address - Country:US
Mailing Address - Phone:704-720-7770
Mailing Address - Fax:704-973-9187
Practice Address - Street 1:245 LE PHILLIP CT NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2900
Practice Address - Country:US
Practice Address - Phone:704-720-7770
Practice Address - Fax:704-973-9187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-013-124101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005393Medicaid