Provider Demographics
NPI:1609483809
Name:GANTT, SHYTAZIA ARIEL
Entity Type:Individual
Prefix:
First Name:SHYTAZIA
Middle Name:ARIEL
Last Name:GANTT
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 1:140 E ROME BLVD # 109813
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-1417
Mailing Address - Country:US
Mailing Address - Phone:702-465-7634
Mailing Address - Fax:
Practice Address - Street 1:140 E ROME BLVD # 109813
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-1417
Practice Address - Country:US
Practice Address - Phone:702-565-7634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician