Healthcare Provider Details

I. General information

NPI: 1336800226
Provider Name (Legal Business Name): ELIZABETH MAXINE GANNON LLMSW, QIDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

493 W NORTON AVE STE C
NORTON SHORES MI
49444-3748
US

IV. Provider business mailing address

493 W NORTON AVE STE C
NORTON SHORES MI
49444-3748
US

V. Phone/Fax

Practice location:
  • Phone: 616-319-4389
  • Fax:
Mailing address:
  • Phone: 616-319-4389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851120958
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: