Healthcare Provider Details

I. General information

NPI: 1619522687
Provider Name (Legal Business Name): CAITLYN ALISON GANNON CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date: 06/15/2026
Reactivation Date: 07/20/2026

III. Provider practice location address

34 JAMES ST
GREENFIELD MA
01301-3608
US

IV. Provider business mailing address

34 JAMES ST
GREENFIELD MA
01301-3608
US

V. Phone/Fax

Practice location:
  • Phone: 774-994-2555
  • Fax:
Mailing address:
  • Phone: 774-994-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP96093
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: