Provider Demographics
NPI:1558816413
Name:SANDY MAE GANNON COMPANY PLC
Entity Type:Organization
Organization Name:SANDY MAE GANNON COMPANY PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:LISW, ACSW
Authorized Official - Phone:319-621-5416
Mailing Address - Street 1:3217 RAVEN ST
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245-5129
Mailing Address - Country:US
Mailing Address - Phone:319-621-5416
Mailing Address - Fax:
Practice Address - Street 1:103 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH ENGLISH
Practice Address - State:IA
Practice Address - Zip Code:52316-9504
Practice Address - Country:US
Practice Address - Phone:319-664-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-22
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00590261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)