Provider Demographics
NPI:1174650329
Name:GANNON, TAMI (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:TAMI
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 884
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-0884
Mailing Address - Country:US
Mailing Address - Phone:360-536-2054
Mailing Address - Fax:
Practice Address - Street 1:2528 WHEATON WAY STE 106
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3305
Practice Address - Country:US
Practice Address - Phone:360-782-1933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00011277101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health