Provider Demographics
NPI:1356008841
Name:GANNON, VICKI
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GLENSHAW
Mailing Address - State:PA
Mailing Address - Zip Code:15116-2430
Mailing Address - Country:US
Mailing Address - Phone:717-341-5609
Mailing Address - Fax:
Practice Address - Street 1:NEW KENSINGTON FHC
Practice Address - Street 2:1072 5TH AVE
Practice Address - City:NEW KENSINGTON
Practice Address - State:PA
Practice Address - Zip Code:15068
Practice Address - Country:US
Practice Address - Phone:724-334-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0221831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical