Provider Demographics
NPI:1801126909
Name:GANT, TIMOTHY (LPC, LCAS, CSI)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:GANT
Suffix:
Gender:M
Credentials:LPC, LCAS, CSI
Other - Prefix:
Other - First Name:TIM
Other - Middle Name:
Other - Last Name:GANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC, LCAS, ICAADC
Mailing Address - Street 1:4140 FERNCREEK DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2563
Mailing Address - Country:US
Mailing Address - Phone:910-321-6006
Mailing Address - Fax:866-852-2281
Practice Address - Street 1:4140 FERNCREEK DR
Practice Address - Street 2:SUITE 300
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2563
Practice Address - Country:US
Practice Address - Phone:910-321-6006
Practice Address - Fax:866-852-2281
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8839101YP2500X, 101YM0800X, 101Y00000X
NC1876101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601052Medicaid