Healthcare Provider Details

I. General information

NPI: 1538462312
Provider Name (Legal Business Name): STEPHEN MICHAEL GANNON LADC1
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 MANCHESTER ST STE 5A
CONCORD NH
03301-5101
US

IV. Provider business mailing address

117 MANCHESTER ST STE 5A
CONCORD NH
03301-5101
US

V. Phone/Fax

Practice location:
  • Phone: 603-606-9357
  • Fax:
Mailing address:
  • Phone: 603-606-9357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1561
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22822
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: