Healthcare Provider Details

I. General information

NPI: 1225162381
Provider Name (Legal Business Name): MICHAEL GANZ PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 31403 BOX 13
APO AE
09630-1403
US

IV. Provider business mailing address

CMR 427 BOX 3193
APO AE
09630-0032
US

V. Phone/Fax

Practice location:
  • Phone: 011390444619140
  • Fax:
Mailing address:
  • Phone: 011390444619530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY 1163
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: