Healthcare Provider Details

I. General information

NPI: 1790802932
Provider Name (Legal Business Name): THOMAS FRANCIS GANNON L.I.S.W.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24100 CHAGRIN BLVD STE 400
BEACHWOOD OH
44122-5545
US

IV. Provider business mailing address

25700 SCEIENCE PARK DRIVE. SUITE 200 LANDMARK CENTRE.
BEACHWOOD OH
44122
US

V. Phone/Fax

Practice location:
  • Phone: 440-831-1040
  • Fax: 440-831-2667
Mailing address:
  • Phone: 216-831-1040
  • Fax: 216-831-2667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0002363 SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: