Provider Demographics
NPI:1982976353
Name:GANTT, STEPHANIE F
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:F
Last Name:GANTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 WHISPERING SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-3657
Mailing Address - Country:US
Mailing Address - Phone:702-417-5172
Mailing Address - Fax:
Practice Address - Street 1:4901 WHISPERING SPRING AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-3657
Practice Address - Country:US
Practice Address - Phone:702-417-5172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV45-3558217Medicaid