Healthcare Provider Details

I. General information

NPI: 1699028431
Provider Name (Legal Business Name): KEITH GANCI PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S SHARON AMITY RD STE 500
CHARLOTTE NC
28211-2896
US

IV. Provider business mailing address

2301 BRANDON CIR
CHARLOTTE NC
28211-1656
US

V. Phone/Fax

Practice location:
  • Phone: 704-362-1555
  • Fax:
Mailing address:
  • Phone: 631-334-1852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number4800
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: