Provider Demographics
NPI:1417042151
Name:GANT, MICHELLE M (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:GANT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:M
Other - Last Name:HUMMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1940 TOWN PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-7855
Mailing Address - Country:US
Mailing Address - Phone:303-896-9828
Mailing Address - Fax:
Practice Address - Street 1:1940 TOWN PARK BLVD
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685-7855
Practice Address - Country:US
Practice Address - Phone:330-896-9829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT010920225100000X
OHPT10920225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2681923Medicaid
OH2681923Medicaid