Provider Demographics
NPI:1306527734
Name:GANTT, DESIRAE (RBT)
Entity type:Individual
Prefix:
First Name:DESIRAE
Middle Name:
Last Name:GANTT
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 WILLOW BREEZE CT
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27597-9703
Mailing Address - Country:US
Mailing Address - Phone:984-302-5018
Mailing Address - Fax:
Practice Address - Street 1:525 WILLOW BREEZE CT
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-9703
Practice Address - Country:US
Practice Address - Phone:984-302-5018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23-285978106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty