MEDICARE: SANDRA M. GANNON LISW

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	1041C0700X	Clinical Social Worker	00590	IA

General Provider Information

NPI Number	:	1770562613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA M. GANNON LISW

Provider Business Mailing Address
First Line	:	P.O. BOX 189
Second Line	:	103 SOUTH MAIN STREET
City	:	NORTH ENGLISH
State	:	IA
Zip	:	52316
Country	:	US
Telephone Number	:	319-664-3333
Fax Number	:	844-448-5484

Provider Business Practice Location Address
First Line	:	103 SOUTH MAIN STREET
Second Line	:
City	:	NORTH ENGLISH
State	:	IA
Zip	:	52316
Country	:	US
Telephone Number	:	319-664-3333
Fax Number	:	844-448-5484

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

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	06/16/2016

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