Healthcare Provider Details

I. General information

NPI: 1851989776
Provider Name (Legal Business Name): HANNAH JEAN GELLERSTEDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2021
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N FREEDOM BLVD
PROVO UT
84601-1677
US

IV. Provider business mailing address

750 N FREEDOM BLVD
PROVO UT
84601-1677
US

V. Phone/Fax

Practice location:
  • Phone: 801-373-4760
  • Fax: 801-373-0639
Mailing address:
  • Phone: 801-373-4760
  • Fax: 801-373-0639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number13356859-3503
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13356859-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: