Provider Demographics
NPI:1346493434
Name:GANNON, KAREN MARIE (CSP)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:MARIE
Last Name:GANNON
Suffix:
Gender:F
Credentials:CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 JON BARRETT RD
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:NY
Mailing Address - Zip Code:12563-2164
Mailing Address - Country:US
Mailing Address - Phone:845-878-9078
Mailing Address - Fax:845-278-6984
Practice Address - Street 1:15 MOUNT EBO RD S
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-4004
Practice Address - Country:US
Practice Address - Phone:845-878-9078
Practice Address - Fax:845-278-6984
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1937289103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool