Provider Demographics
NPI:1164668703
Name:GANT, LARRY M (LMSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:M
Last Name:GANT
Suffix:
Gender:M
Credentials:LMSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 97
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48068-0097
Mailing Address - Country:US
Mailing Address - Phone:313-725-1847
Mailing Address - Fax:313-347-4369
Practice Address - Street 1:418 N. MAIN STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-1813
Practice Address - Country:US
Practice Address - Phone:313-725-1847
Practice Address - Fax:313-347-4369
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-04
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801057231104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker