Provider Demographics
NPI:1164530812
Name:GANN, MICHAEL KELLY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KELLY
Last Name:GANN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3862 STARFIELD LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8032
Mailing Address - Country:US
Mailing Address - Phone:702-333-2907
Mailing Address - Fax:702-333-2693
Practice Address - Street 1:1180 N TOWN CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6363
Practice Address - Country:US
Practice Address - Phone:702-333-2907
Practice Address - Fax:702-333-2693
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY0791103TB0200X
AZ3413103TC0700X
CAPSY26848103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral