Provider Demographics
NPI:1144742669
Name:GANNON, TAYLOR ELIZABETH (OTR)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ELIZABETH
Last Name:GANNON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 PALMETTO COVE CT
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-9580
Mailing Address - Country:US
Mailing Address - Phone:630-986-7714
Mailing Address - Fax:
Practice Address - Street 1:1127 QUEENSBOROUGH BLVD STE 104
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5431
Practice Address - Country:US
Practice Address - Phone:843-216-0290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist