Provider Demographics
NPI:1003562869
Name:GANICK, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:GANICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 OUCHONDER RD
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:38560-4232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:89 OUCHONDER RD
Practice Address - Street 2:
Practice Address - City:ELMWOOD
Practice Address - State:TN
Practice Address - Zip Code:38560-4232
Practice Address - Country:US
Practice Address - Phone:615-579-6241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1156561041C0700X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP-IND4MBYJ6QCTX-00OtherNASW LIABILITY INSURANCE