1801126909 NPI number — TIMOTHY GANT LPC, LCAS, CSI

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801126909 NPI number — TIMOTHY GANT LPC, LCAS, CSI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANT
Provider First Name:
TIMOTHY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, LCAS, CSI
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GANT
Provider Other First Name:
TIM
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC, LCAS, ICAADC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1801126909
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4140 FERNCREEK DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28314-2563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-321-6006
Provider Business Mailing Address Fax Number:
866-852-2281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4140 FERNCREEK DR
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28314-2563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-321-6006
Provider Business Practice Location Address Fax Number:
866-852-2281
Provider Enumeration Date:
01/12/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  8839 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , with the licence number: 1876 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 8839 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X , with the licence number: 8839 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6601052 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".