Provider Demographics
NPI:1902464969
Name:GANT, MICHANDA
Entity Type:Individual
Prefix:
First Name:MICHANDA
Middle Name:
Last Name:GANT
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 1:7244 COTTONWOOD KNL
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4045
Mailing Address - Country:US
Mailing Address - Phone:248-915-9372
Mailing Address - Fax:
Practice Address - Street 1:18244 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-4163
Practice Address - Country:US
Practice Address - Phone:313-964-3886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI104100000X
MI6801113666104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker