Basic Information
| Provider Information | |||||||||
| NPI: | 1073615589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANNAWAY | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 VICTORY DRIVE | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168832660 | ||||||||
| FaxNumber: | 8167929819 | ||||||||
| Practice Location | |||||||||
| Address1: | 3143 W JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604354733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157446898 | ||||||||
| FaxNumber: | 8157442486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2006 | ||||||||
| LastUpdateDate: | 03/26/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 147000243 | IL | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.