MEDICARE: MS. STEPHANIE GANSERT PSY.D.

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	103T00000X	Psychologist	PY6817	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PY6817	OTHER	FL	STATE LICENSE FL

General Provider Information

NPI Number	:	1427087550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STEPHANIE GANSERT PSY.D.

Provider Business Mailing Address
First Line	:	1830 SW 36TH AVE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-3631
Country	:	US
Telephone Number	:	954-540-4960
Fax Number	:

Provider Business Practice Location Address
First Line	:	15127 JOG RD
Second Line	:	SUITE 106
City	:	DELRAY BEACH
State	:	FL
Zip	:	33446-1251
Country	:	US
Telephone Number	:	561-495-6300
Fax Number	:	561-495-8877

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

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	07/08/2007

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