Provider Demographics
NPI:1548754179
Name:GANNON, ANNETTE MICHELLE
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MICHELLE
Last Name:GANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2218 ALGER RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-5805
Mailing Address - Country:US
Mailing Address - Phone:216-645-6214
Mailing Address - Fax:
Practice Address - Street 1:6200 ROCKSIDE WOODS BLVD N
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2333
Practice Address - Country:US
Practice Address - Phone:215-525-1885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator