Provider Demographics
NPI:1023638004
Name:OWENS-GANTT, CARTIER
Entity type:Individual
Prefix:
First Name:CARTIER
Middle Name:
Last Name:OWENS-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 1:1517 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-3822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:202 E AIRPORT DR STE 265
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3444
Practice Address - Country:US
Practice Address - Phone:626-422-1213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA117126106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health