Provider Demographics
NPI:1750593281
Name:GANTT PSYCHOTHERAPEUTIC AND CONSULTATION SERVICES
Entity type:Organization
Organization Name:GANTT PSYCHOTHERAPEUTIC AND CONSULTATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TOMEKA
Authorized Official - Middle Name:MAYS
Authorized Official - Last Name:GANTT
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:704-968-4893
Mailing Address - Street 1:10234 KELSO CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-6637
Mailing Address - Country:US
Mailing Address - Phone:704-968-4893
Mailing Address - Fax:704-583-0672
Practice Address - Street 1:10234 KELSO CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-6637
Practice Address - Country:US
Practice Address - Phone:704-968-4893
Practice Address - Fax:704-583-0672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4417251S00000X, 101YP2500X
SC4620101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102506Medicaid