Provider Demographics
NPI:1730840752
Name:GRUNDVIG, HANNAH BEATRICE
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:BEATRICE
Last Name:GRUNDVIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:BEATRICE
Other - Last Name:BASSETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:80 W 880 N APT 6
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5170
Mailing Address - Country:US
Mailing Address - Phone:408-460-3575
Mailing Address - Fax:
Practice Address - Street 1:3355 N UNIVERSITY AVE STE 250
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6640
Practice Address - Country:US
Practice Address - Phone:801-341-9066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-02
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12436087-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist