MEDICARE: KAJZOO GRACE 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	106S00000X	Behavior Technician	CB60883859	WA

General Provider Information

NPI Number	:	1861971202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAJZOO GRACE HANSON

Provider Business Mailing Address
First Line	:	3515 S ORCHARD ST APT E12
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98466-6785
Country	:	US
Telephone Number	:	612-845-9302
Fax Number	:

Provider Business Practice Location Address
First Line	:	3515 S ORCHARD ST APT E12
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98466-6785
Country	:	US
Telephone Number	:	612-845-9302
Fax Number	:

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

Provider Enumeration Date	:	08/07/2018
Last Update Date	:	08/07/2018

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