Provider Demographics
NPI:1760010227
Name:GAMMON, LAWANDA R
Entity Type:Individual
Prefix:
First Name:LAWANDA
Middle Name:R
Last Name:GAMMON
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 1:4003 KEATON CT
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3139
Mailing Address - Country:US
Mailing Address - Phone:757-641-9004
Mailing Address - Fax:
Practice Address - Street 1:2107 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23324-3527
Practice Address - Country:US
Practice Address - Phone:757-494-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000036103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool