Provider Demographics
NPI:1548243413
Name:GANNON, THERESA (PHD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 50TH ST
Mailing Address - Street 2:UCDHS- MIND INSTITUTE
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2308
Mailing Address - Country:US
Mailing Address - Phone:916-703-0290
Mailing Address - Fax:
Practice Address - Street 1:2825 50TH ST
Practice Address - Street 2:UCDHS- MIND INSTITUTE
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2308
Practice Address - Country:US
Practice Address - Phone:916-703-0290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16008103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY16008OtherPSYCHOLOGIST LICENSE #
CAGR002104MOtherMEDI-CAL GROUP NUMBER
CA06999BMedicare UPIN