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NPI Code Detail

MEDICARE: MCKENZIE ROSE GANNON

MEDICARE: MCKENZIE ROSE GANNON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker136250CA
2390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1447952528
Entity Type Code : Individual
Provider Name (Legal Business Name) : MCKENZIE ROSE GANNON
Provider Business Mailing Address
First Line : 707 FAIR AVE
Second Line :
City : SANTA CRUZ
State : CA
Zip : 95060-5828
Country : US
Telephone Number : 831-427-1007
Fax Number : 831-454-0545
Provider Business Practice Location Address
First Line : 707 FAIR AVE
Second Line :
City : SANTA CRUZ
State : CA
Zip : 95060-5828
Country : US
Telephone Number : 831-427-1007
Fax Number : 831-454-0545
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/21/2023
Last Update Date : 01/05/2026

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Directions to “ MCKENZIE ROSE GANNON ” Practice Location

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