| Generative Therapy Center | |
|
968 Summit Ln Ellijay GA 30540-8728 | |
| (646) 582-9774 | |
| Not Available |
| Full Name | Generative Therapy Center |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 968 Summit Ln, Ellijay, Georgia |
| Authorized Official Name and Position | Michel Bordeau (OWNER) |
| Authorized Official Contact | 6465829774 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Generative Therapy Center 968 Summit Ln # 1042 Ellijay GA 30540-8728 Ph: (646) 582-9774 | Generative Therapy Center 968 Summit Ln Ellijay GA 30540-8728 Ph: (646) 582-9774 |
| NPI Number | 1861976144 |
|---|---|
| Provider Enumeration Date | 09/21/2018 |
| Last Update Date | 05/17/2019 |
| Medicare PECOS PAC ID | 6305189226 |
|---|---|
| Medicare Enrollment ID | O20190516001967 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1861976144 | NPI | - | NPPES |
| CSW006489 | Other | GA | PROFESSIONAL LICENSE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| Provider Name | Michel Bordeau |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1215324397 PECOS PAC ID: 7113260035 Enrollment ID: I20190522002269 |
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