Provider Demographics
NPI:1548738339
Name:GANTOS, DUSTIN LUKE (LPCA)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:LUKE
Last Name:GANTOS
Suffix:
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 TURNER DR
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-5736
Mailing Address - Country:US
Mailing Address - Phone:336-349-2233
Mailing Address - Fax:
Practice Address - Street 1:229 TURNER DR
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5736
Practice Address - Country:US
Practice Address - Phone:336-349-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14119101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional