Provider Demographics
NPI:1508006883
Name:GANNON, DESIREE KOPIL (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:KOPIL
Last Name:GANNON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:DESIREE
Other - Middle Name:MARIE
Other - Last Name:KOPIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:131 SAFRAN AVE
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-3205
Mailing Address - Country:US
Mailing Address - Phone:732-742-3749
Mailing Address - Fax:732-709-3388
Practice Address - Street 1:131 SAFRAN AVE
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-3205
Practice Address - Country:US
Practice Address - Phone:732-742-3749
Practice Address - Fax:732-709-3388
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008498-1225XP0200X
NJ46TR00098800225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics