Healthcare Provider Details

I. General information

NPI: 1558030999
Provider Name (Legal Business Name): GENEVIEVE WILKERSON HANSEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 N 4TH W
REXBURG ID
83440-1415
US

IV. Provider business mailing address

146 N 4TH W
REXBURG ID
83440-1415
US

V. Phone/Fax

Practice location:
  • Phone: 707-815-3858
  • Fax:
Mailing address:
  • Phone: 707-815-3858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: GENEVIEVE MARIE WILKERSON HANSEN
Title or Position: INTERVENTION PROFESSIONAL
Credential:
Phone: 707-815-3858