Provider Demographics
NPI:1699192617
Name:GAMMON, FRED (T-LAC)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:GAMMON
Suffix:
Gender:M
Credentials:T-LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:KS
Mailing Address - Zip Code:66770-0550
Mailing Address - Country:US
Mailing Address - Phone:620-848-2300
Mailing Address - Fax:620-848-2301
Practice Address - Street 1:6610 SE QUAKERVALE RD
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:KS
Practice Address - Zip Code:66770-4185
Practice Address - Country:US
Practice Address - Phone:620-848-2300
Practice Address - Fax:620-848-2301
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1139101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)