Provider Demographics
NPI:1073691119
Name:GANNON, JOHN (MS FPPR)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:GANNON
Suffix:
Gender:M
Credentials:MS FPPR
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:GANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS FPPR
Mailing Address - Street 1:2640 AQUETONG RD
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:PA
Mailing Address - Zip Code:18938-5602
Mailing Address - Country:US
Mailing Address - Phone:215-862-1302
Mailing Address - Fax:
Practice Address - Street 1:2640 AQUETONG RD
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:PA
Practice Address - Zip Code:18938-5602
Practice Address - Country:US
Practice Address - Phone:215-862-1302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006769L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist