Provider Demographics
NPI:1659806925
Name:GANN, MICHAEL CHAD (MA, MA, LP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHAD
Last Name:GANN
Suffix:
Gender:M
Credentials:MA, MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 DORSEY ST
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-5650
Mailing Address - Country:US
Mailing Address - Phone:817-797-7116
Mailing Address - Fax:
Practice Address - Street 1:1000 DORSEY ST
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5650
Practice Address - Country:US
Practice Address - Phone:817-797-7116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer