Provider Demographics
NPI:1134495971
Name:GANTT, LAKEISHA SHONTA (PHD)
Entity type:Individual
Prefix:
First Name:LAKEISHA
Middle Name:SHONTA
Last Name:GANTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 SWANSON DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3219
Mailing Address - Country:US
Mailing Address - Phone:706-389-8207
Mailing Address - Fax:
Practice Address - Street 1:2750 LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-2406
Practice Address - Country:US
Practice Address - Phone:706-389-8207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006380101YP2500X
GAPSY003777103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional