Provider Demographics
NPI:1669609780
Name:GANTMAN, ALEXANDER (PSYD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:GANTMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12053 EMELITA ST
Mailing Address - Street 2:#7
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607
Mailing Address - Country:US
Mailing Address - Phone:323-547-6760
Mailing Address - Fax:
Practice Address - Street 1:12053 EMELITA ST
Practice Address - Street 2:#7
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607
Practice Address - Country:US
Practice Address - Phone:323-547-6760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY236950Medicaid
CAEE504ZMedicare PIN