1982875985 NPI number — MARY GANTT PT

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 1982875985 NPI number — MARY GANTT PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANTT
Provider First Name:
MARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCNEIL
Provider Other First Name:
MARY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982875985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22426 ALTON CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOVI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48375-3801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-504-3824
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19701 VERNIER RD
Provider Second Line Business Practice Location Address:
UITE280
Provider Business Practice Location Address City Name:
HARPER WOODS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48225-1467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-884-8920
Provider Business Practice Location Address Fax Number:
313-884-8510
Provider Enumeration Date:
03/18/2008

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: 225100000X , with the licence number:  5501003654 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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