Provider Demographics
NPI:1811270275
Name:GANNON, REBECCA (LCSW)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 ALAN CT
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-5302
Mailing Address - Country:US
Mailing Address - Phone:646-236-2848
Mailing Address - Fax:
Practice Address - Street 1:14 ALAN CT
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-5302
Practice Address - Country:US
Practice Address - Phone:646-346-2848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY084271-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker