Provider Demographics
NPI:1114291150
Name:GANDY, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:GANDY
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 1:400 S HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1017
Mailing Address - Country:US
Mailing Address - Phone:817-335-2583
Mailing Address - Fax:817-546-3672
Practice Address - Street 1:1710 COUNTRY CLUB DR
Practice Address - Street 2:102
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-2623
Practice Address - Country:US
Practice Address - Phone:817-779-6955
Practice Address - Fax:817-473-9963
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11106237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter