MEDICARE: JOSEPH GANNON, PH.D. A PROFESSIONAL PSYCHOLOGY CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY12034	CA
2	103TB0200X	Cognitive & Behavioral Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OPL120340	OTHER	CA	BLUE SHIELD PROVIDER IDEN

General Provider Information

NPI Number	:	1245277227
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOSEPH GANNON, PH.D. A PROFESSIONAL PSYCHOLOGY CORPORATION

Provider Business Mailing Address
First Line	:	4445 EASTGATE MALL PMB 843
Second Line	:	SUITE 200
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1979
Country	:	US
Telephone Number	:	858-705-5439
Fax Number	:	858-771-1078

Provider Business Practice Location Address
First Line	:	4445 EASTGATE MALL PMB 843
Second Line	:	SUITE 200
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-1979
Country	:	US
Telephone Number	:	858-705-5439
Fax Number	:	858-771-1078

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOSEPH PATRICK GANNON
Credential	:	PH.D.
Telephone Number	:	858-705-5439

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	08/28/2024

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