Provider Demographics
NPI:1770516700
Name:GANNON-MOFFETT, ELIZABETH (LICSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GANNON-MOFFETT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:ROLLINSFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03869-0395
Mailing Address - Country:US
Mailing Address - Phone:603-312-0731
Mailing Address - Fax:
Practice Address - Street 1:3 FRONT ST
Practice Address - Street 2:SUITE 351
Practice Address - City:ROLLINSFORD
Practice Address - State:NH
Practice Address - Zip Code:03869-7001
Practice Address - Country:US
Practice Address - Phone:603-312-0731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH11821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30423878Medicaid
NH14Y009951NH01OtherANTHEM BLUE CROSS