Provider Demographics
NPI:1831374008
Name:GANNON, RAYMOND F (LMHC, LPC)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:F
Last Name:GANNON
Suffix:
Gender:M
Credentials:LMHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7059 E HIGHWAY 318
Mailing Address - Street 2:
Mailing Address - City:CITRA
Mailing Address - State:FL
Mailing Address - Zip Code:32113-2742
Mailing Address - Country:US
Mailing Address - Phone:848-333-5546
Mailing Address - Fax:
Practice Address - Street 1:1009 MAITLAND CENTER COMMONS BLVD STE 212
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7270
Practice Address - Country:US
Practice Address - Phone:848-333-5546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00364400101YP2500X
FLMH12846101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029807Medicaid
NJ526788OtherMEDICARE GROUP #