Provider Demographics
NPI:1689738999
Name:GANTT, TOMEKA MAYS (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:TOMEKA
Middle Name:MAYS
Last Name:GANTT
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9029 GERALD DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-3080
Mailing Address - Country:US
Mailing Address - Phone:704-968-4893
Mailing Address - Fax:
Practice Address - Street 1:452 LAKESHORE PKWY STE 230
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4291
Practice Address - Country:US
Practice Address - Phone:704-968-4893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4417101YP2500X
SC4620101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102506Medicaid