Provider Demographics
NPI:1710287784
Name:GANNON, KERRI J
Entity Type:Individual
Prefix:MISS
First Name:KERRI
Middle Name:J
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 1:70 DEDERER ST
Mailing Address - Street 2:
Mailing Address - City:SPARKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10976-1107
Mailing Address - Country:US
Mailing Address - Phone:845-548-3183
Mailing Address - Fax:
Practice Address - Street 1:5 BRADHURST AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2135
Practice Address - Country:US
Practice Address - Phone:914-592-8526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352173091235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist