MEDICARE: MARY E GANNON MA PCC

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	101YP2500X	Professional Counselor	E.0900421	OH

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
2	822511633	OTHER	OH	TAX ID

General Provider Information

NPI Number	:	1821337445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY E GANNON MA PCC

Provider Business Mailing Address
First Line	:	918 E SCHAAF RD
Second Line	:
City	:	BROOKLYN HEIGHTS
State	:	OH
Zip	:	44131-1224
Country	:	US
Telephone Number	:	216-543-4359
Fax Number	:

Provider Business Practice Location Address
First Line	:	2020 W SCHAAF RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44109-4608
Country	:	US
Telephone Number	:	614-706-7554
Fax Number	:

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

Provider Enumeration Date	:	02/01/2013
Last Update Date	:	01/14/2022

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