Provider Demographics
NPI:1538462312
Name:GANNON, STEPHEN MICHAEL (LADC1)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:GANNON
Suffix:
Gender:M
Credentials:LADC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 LOWELL ST APT 3309
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-4549
Mailing Address - Country:US
Mailing Address - Phone:617-529-5511
Mailing Address - Fax:
Practice Address - Street 1:75 LINDALL ST
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-2121
Practice Address - Country:US
Practice Address - Phone:617-529-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-16
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
MA22822101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251B00000XAgenciesCase Management