Provider Demographics
NPI:1952814709
Name:GANNON, KASI BROOK (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KASI
Middle Name:BROOK
Last Name:GANNON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2016 S MAYO TRL
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-2295
Mailing Address - Country:US
Mailing Address - Phone:606-422-3200
Mailing Address - Fax:
Practice Address - Street 1:2016 S MAYO TRL
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-2295
Practice Address - Country:US
Practice Address - Phone:606-422-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175362225X00000X
KY240762225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY240762Medicaid
KY240762OtherLICENSE NUMBER
KY175362OtherMEDICARE
KY175362OtherUPIN