Provider Demographics
NPI:1760540405
Name:GAMMON, RONALD JOHN (CADCIII CCS)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:JOHN
Last Name:GAMMON
Suffix:
Gender:M
Credentials:CADCIII CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NORTH SHORE CENTER
Mailing Address - Street 2:10303 N PORT WASHINGTON RD SQ 203
Mailing Address - City:MEGUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092
Mailing Address - Country:US
Mailing Address - Phone:262-241-5955
Mailing Address - Fax:262-241-5926
Practice Address - Street 1:NORTH SHORE CENTER
Practice Address - Street 2:10303 N PORT WASHINGTON RD SQ 203
Practice Address - City:MEGUON
Practice Address - State:WI
Practice Address - Zip Code:53092
Practice Address - Country:US
Practice Address - Phone:262-241-5955
Practice Address - Fax:262-241-5926
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2136101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
84437Medicare ID - Type Unspecified