Provider Demographics
NPI:1649500372
Name:GANT, TERESA DIANNE (CASE MANAGER)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:DIANNE
Last Name:GANT
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22007 COUNTY ROAD EW 185
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:OK
Mailing Address - Zip Code:73542-9118
Mailing Address - Country:US
Mailing Address - Phone:580-335-5411
Mailing Address - Fax:
Practice Address - Street 1:22007 COUNTY ROAD EW 185
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:OK
Practice Address - Zip Code:73542-9118
Practice Address - Country:US
Practice Address - Phone:580-335-5411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-31
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20174171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator