Provider Demographics
NPI:1659417616
Name:GANNON, MOLLY A (SLP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:A
Last Name:GANNON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 FOX FIRE DR
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-6558
Mailing Address - Country:US
Mailing Address - Phone:920-426-8463
Mailing Address - Fax:
Practice Address - Street 1:3305 N BALLARD RD STE C
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-9001
Practice Address - Country:US
Practice Address - Phone:920-735-9234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1408235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42754200Medicaid