Provider Demographics
NPI:1801406103
Name:GANNON, BARBARA KELLOGG (PSYD)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:KELLOGG
Last Name:GANNON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 WESTERN AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-3664
Mailing Address - Country:US
Mailing Address - Phone:978-290-2539
Mailing Address - Fax:
Practice Address - Street 1:30 WESTERN AVE STE 209
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-3664
Practice Address - Country:US
Practice Address - Phone:978-290-2539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7950-PY-PR103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical