Provider Demographics
NPI:1467599944
Name:GANNIS, DARIAN (LCSW, CPRP)
Entity Type:Individual
Prefix:
First Name:DARIAN
Middle Name:
Last Name:GANNIS
Suffix:
Gender:F
Credentials:LCSW, CPRP
Other - Prefix:
Other - First Name:DARIAN
Other - Middle Name:
Other - Last Name:CACCAVALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 50927
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207
Mailing Address - Country:US
Mailing Address - Phone:602-995-7474
Mailing Address - Fax:602-254-5666
Practice Address - Street 1:40 E MITCHELL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2330
Practice Address - Country:US
Practice Address - Phone:602-995-7474
Practice Address - Fax:602-254-5666
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-103661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLCSW - 10366OtherSOCIAL WORK LICENSE