Provider Demographics
NPI:1780354456
Name:GANNON, KATHERINE
Entity type:Individual
Prefix:
First Name:KATHERINE
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 1:33 KENNEDY ROAD
Mailing Address - Street 2:SUITE 33A
Mailing Address - City:TRANQUILITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07879
Mailing Address - Country:US
Mailing Address - Phone:973-262-0868
Mailing Address - Fax:
Practice Address - Street 1:33 KENNEDY ROAD
Practice Address - Street 2:SUITE 33A
Practice Address - City:TRANQUILITY
Practice Address - State:NJ
Practice Address - Zip Code:07879
Practice Address - Country:US
Practice Address - Phone:908-914-7866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00532800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health