MEDICARE: PAMELA KING-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	106H00000X	Marriage & Family Therapist	MI4029	NV
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1992158224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA KING-GANTT

Provider Business Mailing Address
First Line	:	4037 GASTER AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6697
Country	:	US
Telephone Number	:	702-778-8922
Fax Number	:

Provider Business Practice Location Address
First Line	:	4037 GASTER AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6697
Country	:	US
Telephone Number	:	702-778-8922
Fax Number	:

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

Provider Enumeration Date	:	07/21/2016
Last Update Date	:	06/09/2022

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Directions to “ PAMELA KING-GANTT ” Practice Location

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