Provider Demographics
NPI:1184011132
Name:GANNON, CHRISTINE (OTR)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:MERCIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20331 MAUER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1773
Mailing Address - Country:US
Mailing Address - Phone:586-218-7594
Mailing Address - Fax:
Practice Address - Street 1:20331 MAUER ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1773
Practice Address - Country:US
Practice Address - Phone:586-218-7594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006130225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist