Healthcare Provider Details

I. General information

NPI: 1750593281
Provider Name (Legal Business Name): GANTT PSYCHOTHERAPEUTIC AND CONSULTATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10234 KELSO CT
CHARLOTTE NC
28278-6637
US

IV. Provider business mailing address

10234 KELSO CT
CHARLOTTE NC
28278-6637
US

V. Phone/Fax

Practice location:
  • Phone: 704-968-4893
  • Fax: 704-583-0672
Mailing address:
  • Phone: 704-968-4893
  • Fax: 704-583-0672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4417
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4620
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number4417
License Number StateNC

VIII. Authorized Official

Name: MRS. TOMEKA MAYS GANTT
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: M.A.
Phone: 704-968-4893