Provider Demographics
NPI:1770562613
Name:GANNON, SANDRA M (LISW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:GANNON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 189
Mailing Address - Street 2:103 SOUTH MAIN STREET
Mailing Address - City:NORTH ENGLISH
Mailing Address - State:IA
Mailing Address - Zip Code:52316
Mailing Address - Country:US
Mailing Address - Phone:319-664-3333
Mailing Address - Fax:844-448-5484
Practice Address - Street 1:103 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:NORTH ENGLISH
Practice Address - State:IA
Practice Address - Zip Code:52316
Practice Address - Country:US
Practice Address - Phone:319-664-3333
Practice Address - Fax:844-448-5484
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA005901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI12627Medicare ID - Type Unspecified
IAI20047001Medicare UPIN