Provider Demographics
NPI:1235268541
Name:GANNON, MARY L (MD,CADC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:GANNON
Suffix:
Gender:F
Credentials:MD,CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-5220
Mailing Address - Country:US
Mailing Address - Phone:630-981-4886
Mailing Address - Fax:
Practice Address - Street 1:2625 BUTTERFIELD RD
Practice Address - Street 2:SUITE 103 W
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1234
Practice Address - Country:US
Practice Address - Phone:630-981-4886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360682392084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY234667000OtherMAGELLAN BEHAVIORAL HEALT
KY133348420017OtherHUMANA
KYGANNMARYOtherCORPHEALTH