Provider Demographics
NPI:1649418682
Name:GANNON, SUSAN ANNE (MT-BC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANNE
Last Name:GANNON
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9211 HURON RIVER DR
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MI
Mailing Address - Zip Code:48130-9611
Mailing Address - Country:US
Mailing Address - Phone:734-426-5634
Mailing Address - Fax:
Practice Address - Street 1:9357 GENERAL DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4662
Practice Address - Country:US
Practice Address - Phone:734-454-0866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI08001171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor