Provider Demographics
NPI:1093830580
Name:GANNON, WILLARD A
Entity Type:Individual
Prefix:MR
First Name:WILLARD
Middle Name:A
Last Name:GANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:VILLAS
Mailing Address - State:NJ
Mailing Address - Zip Code:08251-2535
Mailing Address - Country:US
Mailing Address - Phone:609-886-5039
Mailing Address - Fax:
Practice Address - Street 1:700 TOWN BANK RD
Practice Address - Street 2:
Practice Address - City:NORTH CAPE MAY
Practice Address - State:NJ
Practice Address - Zip Code:08204-4411
Practice Address - Country:US
Practice Address - Phone:609-898-8899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YSOO393000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist