Provider Demographics
NPI:1518419423
Name:GANT, SHAICIMAH
Entity Type:Individual
Prefix:
First Name:SHAICIMAH
Middle Name:
Last Name:GANT
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 1:100 LESLIE OAK DRIVE
Mailing Address - Street 2:APT 12202
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058
Mailing Address - Country:US
Mailing Address - Phone:229-462-4544
Mailing Address - Fax:
Practice Address - Street 1:26 WAVERLY DR
Practice Address - Street 2:APT H
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-1418
Practice Address - Country:US
Practice Address - Phone:973-220-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician