Provider Demographics
NPI:1619589645
Name:GANNON, CAITLIN EILEEN (PHD)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:EILEEN
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 1:6701 BURNET RD APT 259
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-2861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8701 SHOAL CREEK BLVD STE 404
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-6809
Practice Address - Country:US
Practice Address - Phone:512-879-1836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38438103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical