Provider Demographics
NPI:1235590589
Name:GANT, FRED N (LICENSED MARRIAGE AN)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:N
Last Name:GANT
Suffix:
Gender:M
Credentials:LICENSED MARRIAGE AN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18484 HIGHWAY 18
Mailing Address - Street 2:UNIT # 125
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307
Mailing Address - Country:US
Mailing Address - Phone:760-952-3454
Mailing Address - Fax:866-247-9211
Practice Address - Street 1:18484 HIGHWAY 18
Practice Address - Street 2:UNIT # 125
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-952-3454
Practice Address - Fax:866-247-9211
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC40237106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist