MEDICARE: DR. MICHAEL KELLY GANN PHD

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	103TB0200X	Cognitive & Behavioral Psychologist	PY0791	NV
2	103TC0700X	Clinical Psychologist	3413	AZ
3	103TC0700X	Clinical Psychologist	PSY26848	CA

General Provider Information

NPI Number	:	1164530812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL KELLY GANN PHD

Provider Business Mailing Address
First Line	:	3862 STARFIELD LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-8032
Country	:	US
Telephone Number	:	702-333-2907
Fax Number	:	702-333-2693

Provider Business Practice Location Address
First Line	:	1180 N TOWN CENTER DR STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89144-6363
Country	:	US
Telephone Number	:	702-333-2907
Fax Number	:	702-333-2693

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

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	12/27/2017

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Directions to “ DR. MICHAEL KELLY GANN PHD” Practice Location

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