Provider Demographics
NPI:1154922045
Name:WILKERSON HANSEN, GENEVIEVE MARIE
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:MARIE
Last Name:WILKERSON HANSEN
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 1:146 N 4TH W
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1415
Mailing Address - Country:US
Mailing Address - Phone:707-815-3858
Mailing Address - Fax:
Practice Address - Street 1:146 N 4TH W
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1415
Practice Address - Country:US
Practice Address - Phone:707-815-3858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0009285Medicaid
IDA0009299Medicaid