MEDICARE: BETTY GANTT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1073880332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETTY GANTT

Provider Business Mailing Address
First Line	:	7725 N 43RD AVE STE 621
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-5772
Country	:	US
Telephone Number	:	702-672-6478
Fax Number	:

Provider Business Practice Location Address
First Line	:	7725 N 43RD AVE STE 621
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-5772
Country	:	US
Telephone Number	:	623-934-3784
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2011
Last Update Date	:	04/16/2024

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