Basic Information
Provider Information
NPI: 1003140435
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PHELPS
FirstName: GENETTE
MiddleName: MARY
NamePrefix: MS.
NameSuffix:  
Credential: MHS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4512 JESSIE RD
Address2:  
City: MARTINEZ
State: GA
PostalCode: 309079759
CountryCode: US
TelephoneNumber: 7068146779
FaxNumber:  
Practice Location
Address1: 4512 JESSIE RD
Address2:  
City: MARTINEZ
State: GA
PostalCode: 309079759
CountryCode: US
TelephoneNumber: 7068146779
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/02/2009
LastUpdateDate: 10/02/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000XIMH 6160FLY Behavioral Health & Social Service ProvidersCounselor 

No ID Information.


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