Provider Demographics
NPI:1417332149
Name:GANO, GENEVIA M (DOCTORATE)
Entity Type:Individual
Prefix:
First Name:GENEVIA
Middle Name:M
Last Name:GANO
Suffix:
Gender:F
Credentials:DOCTORATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 W BAY AVE
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4124
Mailing Address - Country:US
Mailing Address - Phone:321-422-0829
Mailing Address - Fax:
Practice Address - Street 1:114 W BAY AVE
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4124
Practice Address - Country:US
Practice Address - Phone:321-422-0829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health