Provider Demographics
NPI:1225162381
Name:GANZ, MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:GANZ
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:CMR 427 BOX 3193
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09630-0032
Mailing Address - Country:US
Mailing Address - Phone:01139044-461-9530
Mailing Address - Fax:
Practice Address - Street 1:UNIT 31403 BOX 13
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09630-1403
Practice Address - Country:US
Practice Address - Phone:01139044-461-9140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY 1163103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN