Provider Demographics
NPI:1437412228
Name:GANNAWAY, VERONICA MARION (LCSW)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:MARION
Last Name:GANNAWAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3751 STOCKER ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-5101
Mailing Address - Country:US
Mailing Address - Phone:323-298-3681
Mailing Address - Fax:
Practice Address - Street 1:3751 STOCKER ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-5101
Practice Address - Country:US
Practice Address - Phone:323-298-6008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA775061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800XOtherMEDI-CAL