Basic Information
| Provider Information | |||||||||
| NPI: | 1467599944 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANNIS | ||||||||
| FirstName: | DARIAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, CPRP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CACCAVALE | ||||||||
| OtherFirstName: | DARIAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 50927 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029957474 | ||||||||
| FaxNumber: | 6022545666 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 E MITCHELL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029957474 | ||||||||
| FaxNumber: | 6022545666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-10366 | AZ | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LCSW - 10366 | 01 | AZ | SOCIAL WORK LICENSE | OTHER |