Provider Demographics
NPI:1053342840
Name:GANTNER, ANITA B (PHD)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:B
Last Name:GANTNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 METROHEALTH DR
Mailing Address - Street 2:MHMC-PM&R
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1900
Mailing Address - Country:US
Mailing Address - Phone:216-778-7799
Mailing Address - Fax:
Practice Address - Street 1:2500 METROHEALTH DR
Practice Address - Street 2:MHMC-PM&R
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1900
Practice Address - Country:US
Practice Address - Phone:216-778-7799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4399103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2726468400OtherBWC
OH0861385Medicaid
OHGACP78021Medicare ID - Type Unspecified
OHP09086Medicare UPIN