Basic Information
| Provider Information | |||||||||
| NPI: | 1346493434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANNON | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CSP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 JON BARRETT RD | ||||||||
| Address2: | |||||||||
| City: | PATTERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125632164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458789078 | ||||||||
| FaxNumber: | 8452786984 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 MOUNT EBO RD S | ||||||||
| Address2: | |||||||||
| City: | BREWSTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105094004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458789078 | ||||||||
| FaxNumber: | 8452786984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2008 | ||||||||
| LastUpdateDate: | 11/03/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | 1937289 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.