Provider Demographics
NPI:1669192985
Name:GANN, AMY NICOLE (LISW-CP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:GANN
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 LADSON RD UNIT 1528
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-1783
Mailing Address - Country:US
Mailing Address - Phone:843-737-1620
Mailing Address - Fax:
Practice Address - Street 1:204 N CEDAR ST STE 100
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6453
Practice Address - Country:US
Practice Address - Phone:843-821-2480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC130831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty