Provider Demographics
NPI:1669539706
Name:GANAHL, GARY FRANCIS (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:FRANCIS
Last Name:GANAHL
Suffix:
Gender:M
Credentials:PHD
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Mailing Address - Street 1:1770 CENTURY BLVD NE STE B
Mailing Address - Street 2:SUITE B
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3395
Mailing Address - Country:US
Mailing Address - Phone:404-329-9977
Mailing Address - Fax:404-329-0583
Practice Address - Street 1:1770 CENTURY BLVD NE STE B
Practice Address - Street 2:SUITE B
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3395
Practice Address - Country:US
Practice Address - Phone:404-329-9977
Practice Address - Fax:404-329-0583
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAPSY001192103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000574604GMedicaid