MEDICARE: JONATHAN ADIEL GANGER

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1437920592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN ADIEL GANGER

Provider Business Mailing Address
First Line	:	1430 MASSACHUSETTS AVE
Second Line	:
City	:	CAMBRIDGE
State	:	MA
Zip	:	02138-3831
Country	:	US
Telephone Number	:	646-837-5557
Fax Number	:

Provider Business Practice Location Address
First Line	:	1430 MASSACHUSETTS AVE
Second Line	:
City	:	CAMBRIDGE
State	:	MA
Zip	:	02138-3831
Country	:	US
Telephone Number	:	646-837-5557
Fax Number	:

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

Provider Enumeration Date	:	01/09/2024
Last Update Date	:	01/09/2024

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