Provider Demographics
NPI:1568583243
Name:GANNON, MADONNA ELIZABETH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MADONNA
Middle Name:ELIZABETH
Last Name:GANNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 S JULIAN ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6714
Mailing Address - Country:US
Mailing Address - Phone:630-355-4608
Mailing Address - Fax:
Practice Address - Street 1:70 S RIVER ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-5295
Practice Address - Country:US
Practice Address - Phone:630-844-2662
Practice Address - Fax:630-844-3084
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490110941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
210562Medicare UPIN