Provider Demographics
NPI:1275799926
Name:CANTY, GINGER (MED)
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:
Last Name:CANTY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-1643
Mailing Address - Country:US
Mailing Address - Phone:423-914-9854
Mailing Address - Fax:
Practice Address - Street 1:249 OLIVER EDWARDS RD
Practice Address - Street 2:
Practice Address - City:JONESBOROUGH
Practice Address - State:TN
Practice Address - Zip Code:37659-6537
Practice Address - Country:US
Practice Address - Phone:423-341-6963
Practice Address - Fax:423-753-6952
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-01
Last Update Date:2011-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1519673Medicaid