Provider Demographics
NPI:1659864577
Name:GANNON, MADELINE C (MS)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:C
Last Name:GANNON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 W OAKDALE AVE APT 3A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5331
Mailing Address - Country:US
Mailing Address - Phone:708-557-5994
Mailing Address - Fax:
Practice Address - Street 1:614 W OAKDALE AVE APT 3A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5331
Practice Address - Country:US
Practice Address - Phone:708-557-5994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist