Provider Demographics
NPI:1417626383
Name:GANN, MAXINE L (PHD)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:L
Last Name:GANN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 PARK AVE APT 1K
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1713
Mailing Address - Country:US
Mailing Address - Phone:212-860-3368
Mailing Address - Fax:
Practice Address - Street 1:1199 PARK AVE APT 1K
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1713
Practice Address - Country:US
Practice Address - Phone:212-860-3368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6675103TC0700X
NY7966103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty