Provider Demographics
NPI:1174607329
Name:GENEVA, KATHRYN J (PSYD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:J
Last Name:GENEVA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 12TH ST
Mailing Address - Street 2:SUITE 804
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2462
Mailing Address - Country:US
Mailing Address - Phone:706-322-0265
Mailing Address - Fax:706-322-0266
Practice Address - Street 1:233 12TH ST
Practice Address - Street 2:SUITE 804
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2462
Practice Address - Country:US
Practice Address - Phone:706-322-0265
Practice Address - Fax:706-322-0266
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002694103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA319109573CMedicaid
GA511I680025Medicare UPIN