MEDICARE: SANDY MAE GANNON COMPANY PLC

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
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	00590	IA

General Provider Information

NPI Number	:	1558816413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANDY MAE GANNON COMPANY PLC

Provider Business Mailing Address
First Line	:	3217 RAVEN ST
Second Line	:
City	:	IOWA CITY
State	:	IA
Zip	:	52245-5129
Country	:	US
Telephone Number	:	319-621-5416
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 S MAIN ST
Second Line	:
City	:	NORTH ENGLISH
State	:	IA
Zip	:	52316-9504
Country	:	US
Telephone Number	:	319-664-3333
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. SANDRA MAE GANNON
Credential	:	LISW, ACSW
Telephone Number	:	319-621-5416

Provider Enumeration Date	:	08/22/2016
Last Update Date	:	11/01/2016

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