Provider Demographics
NPI:1366188575
Name:CLARK- GANTT, WANDA LEIGH
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:LEIGH
Last Name:CLARK- GANTT
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 1:3925 N MARTIN L KING BLVD STE 117
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-7675
Mailing Address - Country:US
Mailing Address - Phone:702-610-1715
Mailing Address - Fax:
Practice Address - Street 1:3925 N MARTIN L KING BLVD STE 117
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-7675
Practice Address - Country:US
Practice Address - Phone:702-610-1715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health