Provider Demographics
NPI:1255957346
Name:MMG PSYCHOTHERAPY LLC
Entity type:Organization
Organization Name:MMG PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MBR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GANS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:561-578-9348
Mailing Address - Street 1:520 NE 20TH STREET
Mailing Address - Street 2:#603
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305
Mailing Address - Country:US
Mailing Address - Phone:561-578-9348
Mailing Address - Fax:866-757-5778
Practice Address - Street 1:520 NE 20TH STREET
Practice Address - Street 2:#603
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305
Practice Address - Country:US
Practice Address - Phone:561-578-9348
Practice Address - Fax:866-757-5778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty