Provider Demographics
NPI:1063424588
Name:GANS, MICHAEL (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GANS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1926
Mailing Address - Country:US
Mailing Address - Phone:860-409-4595
Mailing Address - Fax:860-409-4860
Practice Address - Street 1:35 NOD RD
Practice Address - Street 2:102
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3826
Practice Address - Country:US
Practice Address - Phone:860-677-0739
Practice Address - Fax:860-677-1029
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2017-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004262317Medicaid
CT076572Medicare ID - Type UnspecifiedGROUP ID NUMBER