Provider Demographics
NPI:1821337445
Name:GANNON, MARY E (MA PCC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:GANNON
Suffix:
Gender:F
Credentials:MA PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 E SCHAAF RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44131-1224
Mailing Address - Country:US
Mailing Address - Phone:216-543-4359
Mailing Address - Fax:
Practice Address - Street 1:2020 W SCHAAF RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-4608
Practice Address - Country:US
Practice Address - Phone:614-706-7554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-01
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0900421101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid
OH822511633OtherTAX ID