Provider Demographics
NPI:1376023671
Name:DOLGOPOLOVA, GANNA
Entity Type:Individual
Prefix:
First Name:GANNA
Middle Name:
Last Name:DOLGOPOLOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27777 INKSTER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5312
Mailing Address - Country:US
Mailing Address - Phone:857-498-0814
Mailing Address - Fax:
Practice Address - Street 1:44 SCHOOL ST RM 325
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-4209
Practice Address - Country:US
Practice Address - Phone:857-498-0814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2024-04-18
Deactivation Date:2021-06-28
Deactivation Code:
Reactivation Date:2022-03-21
Provider Licenses
StateLicense IDTaxonomies
MA3943-MH-B1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid