Provider Demographics
NPI:1710248257
Name:GANTT, PATRICE DENISE (MED)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:DENISE
Last Name:GANTT
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SHELTON RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23663-2110
Mailing Address - Country:US
Mailing Address - Phone:757-528-7193
Mailing Address - Fax:
Practice Address - Street 1:2708 NE 14TH STREET, SUITE 5,
Practice Address - Street 2:BUTTERFLY EFFECTS
Practice Address - City:POMPANO BEACH,
Practice Address - State:FL
Practice Address - Zip Code:33064
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA222Q00000X222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist