Provider Demographics
NPI:1467181099
Name:LOVELL, GENNA MICHELLE ROSE
Entity Type:Individual
Prefix:
First Name:GENNA
Middle Name:MICHELLE ROSE
Last Name:LOVELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GENNA
Other - Middle Name:MICHELLE ROSE
Other - Last Name:LOVELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:7766 S GREENACRES DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6864
Mailing Address - Country:US
Mailing Address - Phone:541-815-5150
Mailing Address - Fax:
Practice Address - Street 1:2650 S EAGLE RD STE 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6745
Practice Address - Country:US
Practice Address - Phone:986-200-4290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID42345104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker