Provider Demographics
NPI:1407298953
Name:GANNON, TAMMY
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:
Other - Last Name:GANNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:8183 HIGH POINT TRL
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48386-3545
Mailing Address - Country:US
Mailing Address - Phone:734-812-1397
Mailing Address - Fax:
Practice Address - Street 1:8183 HIGH POINT TRL
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48386-3545
Practice Address - Country:US
Practice Address - Phone:734-812-1397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010909371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical