Provider Demographics
NPI:1518447010
Name:GANNON, HALEY (COTA/L)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6430 GREENRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW CARLISLE
Mailing Address - State:OH
Mailing Address - Zip Code:45344-9011
Mailing Address - Country:US
Mailing Address - Phone:937-903-9755
Mailing Address - Fax:
Practice Address - Street 1:25 W PLEASANT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45506-2278
Practice Address - Country:US
Practice Address - Phone:937-325-7671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA007251224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant