Provider Demographics
NPI:1669026829
Name:GANNON, ASHLEY CHRISTA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:CHRISTA
Last Name:GANNON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 ENGLEWOOD AVE APT 17
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-7860
Mailing Address - Country:US
Mailing Address - Phone:603-960-0580
Mailing Address - Fax:
Practice Address - Street 1:68 HARVARD ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7991
Practice Address - Country:US
Practice Address - Phone:888-828-4114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77364-SP-SL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist