Provider Demographics
NPI:1386841088
Name:GANNON, JOHN KEVIN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KEVIN
Last Name:GANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:J. KEVIN
Other - Middle Name:
Other - Last Name:GANNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:M A
Mailing Address - Street 1:623 STAGE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-3206
Mailing Address - Country:US
Mailing Address - Phone:845-783-9840
Mailing Address - Fax:
Practice Address - Street 1:91 HIGH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-3305
Practice Address - Country:US
Practice Address - Phone:845-783-3037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04356235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist