Provider Demographics
NPI:1699028431
Name:GANCI, KEITH (PHD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:GANCI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 BRANDON CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1656
Mailing Address - Country:US
Mailing Address - Phone:631-334-1852
Mailing Address - Fax:
Practice Address - Street 1:501 S SHARON AMITY RD
Practice Address - Street 2:STE 500
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2896
Practice Address - Country:US
Practice Address - Phone:704-362-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4800103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist