Provider Demographics
NPI:1649862913
Name:GANNON, ALLISON
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5357 AUTUMNWINDS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-3005
Mailing Address - Country:US
Mailing Address - Phone:314-471-6463
Mailing Address - Fax:
Practice Address - Street 1:10880 BAUR BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-1632
Practice Address - Country:US
Practice Address - Phone:314-471-6463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019016754101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional