MEDICARE: MS. KIMM GLORIA HANSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	385HR2055X	Child Mental Illness Respite Care	11133	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730242769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMM GLORIA HANSON

Provider Business Mailing Address
First Line	:	2490 W YOWELL CT UNIT 49
Second Line	:
City	:	YUMA
State	:	AZ
Zip	:	85364-1735
Country	:	US
Telephone Number	:	928-539-9298
Fax Number	:

Provider Business Practice Location Address
First Line	:	2490 W YOWELL CT UNIT 49
Second Line	:
City	:	YUMA
State	:	AZ
Zip	:	85364-1735
Country	:	US
Telephone Number	:	928-539-9298
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	07/09/2007

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