Healthcare Provider Details

I. General information

NPI: 1649862913
Provider Name (Legal Business Name): ALLISON GANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10880 BAUR BLVD
SAINT LOUIS MO
63132-1632
US

IV. Provider business mailing address

5357 AUTUMNWINDS DR
SAINT LOUIS MO
63129-3005
US

V. Phone/Fax

Practice location:
  • Phone: 314-471-6463
  • Fax:
Mailing address:
  • Phone: 314-471-6463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2019016754
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: