Provider Demographics
NPI:1104423540
Name:BERTRAM, GENEVIEVE E
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:E
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 BILLY SUNDAY RD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-8113
Mailing Address - Country:US
Mailing Address - Phone:641-251-4343
Mailing Address - Fax:
Practice Address - Street 1:1555 SE DELAWARE AVE STE O
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-4011
Practice Address - Country:US
Practice Address - Phone:515-261-2402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician