=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154901171
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALTER BRANDON GANTT LPC, CSAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2021
-----------------------------------------------------
Last Update Date | 11/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8650 MINNIE BROWN RD
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36117-7803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-324-6588
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8396 TIMBER CREEK DR
-----------------------------------------------------
City | PIKE ROAD
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36064-2276
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-739-1979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LPC05194
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------