Provider Demographics
NPI:1538506332
Name:KEBLIS, GENIE CAROLYN
Entity Type:Individual
Prefix:
First Name:GENIE
Middle Name:CAROLYN
Last Name:KEBLIS
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 1:2835 W 2175 N
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84404-6785
Mailing Address - Country:US
Mailing Address - Phone:801-644-8430
Mailing Address - Fax:
Practice Address - Street 1:934 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-7135
Practice Address - Country:US
Practice Address - Phone:801-336-1845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6794446-3501101YM0800X
UT1538506332101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT13835695Medicaid