Provider Demographics
NPI:1336991272
Name:MANSFIELD, TALON GERVIS
Entity type:Individual
Prefix:
First Name:TALON
Middle Name:GERVIS
Last Name:MANSFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 W 4TH N
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-1439
Mailing Address - Country:US
Mailing Address - Phone:801-400-2977
Mailing Address - Fax:
Practice Address - Street 1:18 S 1ST E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1902
Practice Address - Country:US
Practice Address - Phone:208-656-4484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist