Provider Demographics
NPI:1073615589
Name:GANNAWAY, STEPHEN DALE (MA)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:DALE
Last Name:GANNAWAY
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 VICTORY DRIVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068
Mailing Address - Country:US
Mailing Address - Phone:816-883-2660
Mailing Address - Fax:816-792-9819
Practice Address - Street 1:3143 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-4733
Practice Address - Country:US
Practice Address - Phone:815-744-6898
Practice Address - Fax:815-744-2486
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147000243237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362350Medicare ID - Type UnspecifiedMEDICARE IDENTIFICATION