Provider Demographics
NPI:1467440347
Name:GANNON, JOSEPH PATRICK (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:PATRICK
Last Name:GANNON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4445 EASTGATE MALL STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1979
Mailing Address - Country:US
Mailing Address - Phone:858-705-5439
Mailing Address - Fax:858-771-1078
Practice Address - Street 1:4445 EASTGATE MALL STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1979
Practice Address - Country:US
Practice Address - Phone:858-705-5439
Practice Address - Fax:858-771-1078
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2022-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12034103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL120340OtherBLUE SHIELD/BLUE CROSS
CAOPL120340OtherBLUE SHIELD/BLUE CROSS