Provider Demographics
NPI:1831447523
Name:GANTT, MICHAEL STEPHON
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEPHON
Last Name:GANTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 WHISPERING SPRING AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131
Mailing Address - Country:US
Mailing Address - Phone:702-353-6443
Mailing Address - Fax:
Practice Address - Street 1:5360 SOUTH PECOS ROAD
Practice Address - Street 2:SUITE 2B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120
Practice Address - Country:US
Practice Address - Phone:702-560-5973
Practice Address - Fax:888-753-3302
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health