Healthcare Provider Details

I. General information

NPI: 1831374008
Provider Name (Legal Business Name): RAYMOND F GANNON LMHC, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 MAITLAND CENTER COMMONS BLVD STE 212
MAITLAND FL
32751-7270
US

IV. Provider business mailing address

7059 E HIGHWAY 318
CITRA FL
32113-2742
US

V. Phone/Fax

Practice location:
  • Phone: 848-333-5546
  • Fax:
Mailing address:
  • Phone: 848-333-5546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH12846
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00364400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: