Provider Demographics
NPI:1659732246
Name:GANNON, TARA
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
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 1:19 ERICK CT
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11724-1915
Mailing Address - Country:US
Mailing Address - Phone:631-745-7319
Mailing Address - Fax:
Practice Address - Street 1:19 ERICK CT
Practice Address - Street 2:
Practice Address - City:COLD SPRING HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11724-1915
Practice Address - Country:US
Practice Address - Phone:631-745-7319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist