Healthcare Provider Details

I. General information

NPI: 1245277227
Provider Name (Legal Business Name): JOSEPH GANNON, PH.D. A PROFESSIONAL PSYCHOLOGY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 EASTGATE MALL PMB 843 SUITE 200
SAN DIEGO CA
92121-1979
US

IV. Provider business mailing address

4445 EASTGATE MALL PMB 843 SUITE 200
SAN DIEGO CA
92121-1979
US

V. Phone/Fax

Practice location:
  • Phone: 858-705-5439
  • Fax: 858-771-1078
Mailing address:
  • Phone: 858-705-5439
  • Fax: 858-771-1078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY12034
License Number StateCA

VIII. Authorized Official

Name: DR. JOSEPH PATRICK GANNON
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 858-705-5439