MEDICARE: MOLLY A GANNON SLP

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	235Z00000X	Speech-Language Pathologist	1408	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659417616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY A GANNON SLP

Provider Business Mailing Address
First Line	:	165 FOX FIRE DR
Second Line	:
City	:	OSHKOSH
State	:	WI
Zip	:	54904-6558
Country	:	US
Telephone Number	:	920-426-8463
Fax Number	:

Provider Business Practice Location Address
First Line	:	3360 GATEWAY RD STE 100
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53045-5115
Country	:	US
Telephone Number	:	262-923-7101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	04/30/2024

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Directions to “ MOLLY A GANNON SLP” Practice Location

Language	Start Address	Practice Location

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