Provider Demographics
NPI:1265608632
Name:GANNON, CHRISTINE M (LCSW)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:M
Last Name:GANNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 CAMPUS DR.
Mailing Address - Street 2:CHILDREN'S SYSTEM OF CARE
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097
Mailing Address - Country:US
Mailing Address - Phone:530-841-4100
Mailing Address - Fax:530-841-4799
Practice Address - Street 1:2060 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-9538
Practice Address - Country:US
Practice Address - Phone:530-841-4848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW811201041C0700X
CAASW61631101Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program