Provider Demographics
NPI:1871959833
Name:GANTT, DIANA L (LPC)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:GANTT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5228 NE HOYT ST BLDG B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3055
Mailing Address - Country:US
Mailing Address - Phone:503-215-6474
Mailing Address - Fax:503-215-6477
Practice Address - Street 1:5228 NE HOYT ST BLDG B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3055
Practice Address - Country:US
Practice Address - Phone:503-215-6474
Practice Address - Fax:503-215-6477
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1359101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health