Basic Information
| Provider Information | |||||||||
| NPI: | 1972530186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANNON | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1377 MOTOR PKWY | ||||||||
| Address2: | STE 307 | ||||||||
| City: | ISLANDIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117495258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037542266 | ||||||||
| FaxNumber: | 2035978680 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 CHASE PKWY | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067083346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037542266 | ||||||||
| FaxNumber: | 2035978680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 01/11/2018 | ||||||||
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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 | 225100000X | 002094 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 004203519 | 05 | CT | MEDICAID |